Unity Lifecare | Visitors Registration

Participant Intake Form

We believe no one should face life's challenges alone. By registering your loved one, you're opening doors to compassionate care, personalized support, and an improved quality of life. Take the first step today - help them begin their journey to better days ahead.

Step 1: Participant Information

Participant's name *

Date of birth

Gender *

Male Female Others

Email *

Home phone

Mobile phone

Preferred name

Religious requirements

Cultural requirements

Communication device

Physical assistance

Other considerations

Emergency phone number

Emergency email

Language spoken at home

Residential address *

Postal address: If not the same as residential address

Interpreter required

Yes No

Step 2: Guardian Information

For participants under the age of 18 years, under guardianship, or in the care of family/caregivers, please complete the fields below.

Is there a Guardianship and/or Administration order in place?

Yes No

Guardian 1

Guardian's name

Relationship to participant

Parent Guardian Caregiver Other

Primary carer

Yes No

Lives with participant

Yes No

Residential address

Postal address

Emergency contact

Yes No

Home phone

Mobile phone

Guardian 2

Fill this part only if you have a second guardian

Guardian's name

Relationship to participant

Parent Guardian Caregiver Other

Primary carer

Yes No

Lives with participant

Yes No

Residential address

Postal address

Emergency contact

Yes No

Home Phone

Mobile Phone

Step 3: Behaviour management plan

Is there a behaviour management plan in place?

Yes No

Disability or medical conditions including any diagnosis if relevant

Behaviour support plan documents collected for authorisation purposes

Yes No

Behaviour support plan available on NDIS portal?

Yes No

Step 4: Other service providers

Other service providers currently using (include Specialist behaviour support provider, if relevant)

Is the participant accessing any other support networks/services?

Yes No

Support service 1

Name

Address

Phone

Frequency of use

Support service 2

Fill this part only if you have a second support service

Name

Address

Phone

Frequency of use

Step 5: NDIS details

Medicare number

Expiry date

Reference number

Membership number

Private healthcare provider

Doctor's name

Phone number

Address

NDIS number

NDIS start date

NDIS end date

Do you have NDIS funding?

Yes No

Type of NDIS funding?

Planned managed NDIS managed Self managed Others

Planned management details

Name

Phone number

If you selected "others" please share details below

Additional comments

Step 6: Goals and Aspirations

What do you want to achieve for yourself – life skills, physically, socially etc?

Immediately

In 6 months

Next year

I understand that:

- These records are owned by this organisation.

- Information within these records will be shared with other staff within the organisation on and only when staff require the information to carry out their duties

- I can ask to see records and receive a copy

- Records are archived for a set period according to policy and procedure

- I understand that all information obtained will be kept confidential.

- Please note that the email of the person signing which is required below will be contacted, kindly make sure it is active

- Participants, parent or caregiver's signature initials serves as a signature

To the best of my knowledge, the information provided in this form is true and correct

* Yes, I agree with the privacy policy and terms and conditions.

Participant, parent or caregiver's initials *

Name of person signing*

Email of person signing*

Relationship to the participant, if not the participant

Date

Register

Participant Intake Form

Step 1: Participant Information

Step 2: Guardian Information

Guardian 1

Guardian 2

Step 3: Behaviour management plan

Step 4: Other service providers

Support service 1

Support service 2

Step 5: NDIS details

Planned management details

Step 6: Goals and Aspirations