Intake Assessment Form

AVE MARIA INTAKE ASSESSMENT FORM

"*" indicates required fields

Step 1 of 7

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Participant’s Personal Details

Legal Name*

First

Preferred Name*

First

Date of Birth*

DD slash MM slash YYYY

Age*

Gender*

Male

Female

Country of Birth*

Aboriginal/Torres Strait Islander*

Yes

Primary language/s*

Untitled

Hidden

Interpreter required?*

Yes

Allergy details (medication/food etc) ?*

Yes

Untitled

Mobile No.

Landline No.

Email*

Address

Address Line 2

Designated Carer/Emergency contact person’s name*

First

Relationship with Applicant*

Mobile number*

Are there any Guardianship/Trustee/Financial management orders in place?*

Yes

Untitled

Current financial situation*

Income from work

New start Payment

Carers Allowance

DSP Payment

Parenting Payment

Sickness Benefit

Applying for a DSP Payment

Other

Current Accommodation*

Own house

Rent

Supported living

Nursing Home

Department of Housing

Other

Participant’s Disability / Health Details

Primary Disability (mental health/intellectual disability/physical health etc)*

Any other disabilities?*

Clinical Diagnosis (Both Physical and Mental Health)*

Is the participant under Community Treatment Order (CTO)?*

Yes

Date

MM slash DD slash YYYY

Attach recent Medical Summary Report from the medical practitioner here

Max. file size: 2 MB.

Attach current medication list (Including Depot injection) from the treating medical practitioner here

Max. file size: 2 MB.

How many hospital admissions has the consumer had in last 2 years for mental health needs*

When was the hospital admission length of stay?*

Attach hospital discharge summary (if hospitalised in the last 12 months) here

Max. file size: 2 MB.

Attach COVID 19 vaccination certificates here

Max. file size: 2 MB.

Any major surgery in the last 3 years*

Participant’s Current Level of Supports Needs

Participant’s current supports needs*

Supported Independent Living(SIL)

Short term accommodation(STA)

Medium term accommodation(MTA)

Community access

Transport/In-home support

Other

Assistance with Personal care ?*

Details of incontinence (if any)*

Assistance with shopping or cooking?*

Assistance with transport?*

Any special equipment for mobility?*

Any communication or sensory impairment issues?*

Attach a recent Occupational Therapy (OT) Assessment here

Max. file size: 2 MB.

Attach Behaviour Support Plan(BSP) here

Max. file size: 2 MB.

Level of support required (for SIL and SDA)*

Supported Independent living without 24/7 staff support- Low Care

Supported Independent living with 24/7 staff support-Standard Care

Supported Independent living with 24/7 staff support- Complex Care

Participant’s Risk Assessment Details

Risk of fall*

Yes

Risk of wandering*

Yes

History of Alcohol used*

Yes

History of Smoking*

Yes

How much

How often

How many daily

History of Substance use*

Yes

Current user*

Yes

Amphetamines*

Yes

Cannabis/THC*

Yes

How much

How often

How much

How often

Benzodiazepines*

Yes

Any other Recreational drugs*

Yes

How much

How often

Name

How often

Prescription medication*

Yes

Name

How often

Current risk of Withdrawals from any of above*

Yes

Details

Please Provide Details Below Including History/Current (If Required)

History of Suicidal Attempt*

Yes

Current Risk*

High

Medium

Low

History of Self-harm*

Yes

Current Risk*

High

Medium

Low

History of harming others*

Yes

Current Risk*

High

Medium

Low

Sexual Vulnerability*

Yes

Current Risk*

High

Medium

Low

Financial Vulnerability*

Yes

Current Risk*

High

Medium

Low

History of Aggression/violence*

Yes

Current Risk*

High

Medium

Low

History of Property damage*

Yes

Current Risk*

High

Medium

Low

Family History of Mental health illness/Suicide*

Yes

Forensic history or Legal concerns (if required)

Details

Please list any other conditions that the participant may experience that could impact on their ability to function daily tasks (include physical, mental health or intellectual problems)

NDIS Plan Details

NDIS participant number*

NDIS plan start date*

MM slash DD slash YYYY

NDIS plan end date*

MM slash DD slash YYYY

Plan Type*

NDIA

Self-managed

Plan Nominee

Plan management provider

Plan Nominee / Management Provider Details (If Applicable)

Name

Number

Attach the NDIS plan here

Max. file size: 2 MB.

Participant’s Clinical/Non-clinical Support Details

Name of GP*

Contact Details*

Address*

Name of Psychiatrist*

Psychiatrist Contact Details*

Name of Case Manager*

Case Manager Contact Details*

Support Coordinator's Details

Name*

Contact Details*

Email*

Agency / Organisation*

Are you aware of any other agencies supporting this participant (ex: community mental health team, psychologist, counsellor, NGOs etc)*

Yes

Referrer Details

Name*

Relationship to the Participant*

Name of Organisation*

Contact Details*

Email*

Do you have consent from the participant to make this referral?

Yes

Date*

MM slash DD slash YYYY

Please attach any other relevant documents such as Mental health Risk assessment/safety plan etc

Max. file size: 2 MB.

How did you hear from us?*

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All information gathered through this application process is kept strictly confidential and will not be disclosed to any third parties outside of Ave Maria service providers except as may be permitted or required by law.

Intake Form

Intake Form

AVE MARIA INTAKE ASSESSMENT FORM

Participant’s Personal Details

Participant’s Disability / Health Details

Participant’s Current Level of Supports Needs

Participant’s Risk Assessment Details

Please Provide Details Below Including History/Current (If Required)

NDIS Plan Details

Participant’s Clinical/Non-clinical Support Details

Referrer Details

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