Client Intake Pack

FULL CLIENT INTAKE PACK
Agreement to intake Pack

This form was designed to get a digital signature from you showing that you have gone through the intake process with one of our Care Staff and received an email with a PDF attached of the documents we have completed with you.

Please press next to go to our acknowledgment page so you can digitally sign in your area on the PDF documents you recieved attached to your email.
Client Intake Form

This form was designed to get some basic details from you, a representative or a referral.

Once you have submitted this form, a representative from Caring Lotus will be in contact with you to discuss your needs in a little more detail and walk you through the rest of our intake process.

If you have any issues completing this form, please do not hesitate to get in contact with one of our friendly representatives by calling (03) 7036 1516 so that they can complete it for you over the phone with you.
Name of person completing this form
ie. Client, Representative, etc
Relationship to Client
Self, Mother, Father, Son etc.
Staff Name*
Caring Lotus Staff Name
Title / Position*
Caring Lotus staff title/position
Staff Email*
example@example.com
Date Caring Lotus Completed*

DayMonthYear
Date
Care Manager
Send to client for Signature

YesNo
Medication Self Assessment

DayMonthYear
Medication Plan and Consent

DayMonthYear

Consent Form
Use of Media (please tick)

I do not give the organisation authority to use photographs and videos for therapeuticI do not give the organisation authority to use photographs and videos for marketingI do not give the organisation authority to send me information about services via a NewsletterI do not give the organisation authority to contact me to advise me of service related opportunities

Client Intake Checklist

The below topics have been explained
Topic

Eligibility criteria for entry to the service, and procedures for prioritising accessIndividual’s right to access a support person of their choice to assist them when entering or exiting a service, and in developing their personalised planInformation and support which can be offered to assist individuals using the serviceHow the service works with individuals accessing services to develop a personalised plan to assist them to achieve their goals, and the format of the copy of the plan which will be provided to the individual accessing the serviceProcedures for accessing or nominating a support person of their choiceSupport which will be provided, how the support will be delivered, and how frequently the personalised plan will be reviewedPrivacy and confidentiality policy and procedures in relation to the use of, and access to personal information held about individual accessing servicesProcedures for release of personal information to another party and the requirement for informed consent for releaseHow the individual accessing services can participate in decision making processes to assist the service to improve
Staff Intake Checklist Signature

Clear

Risk Management Plan
- The Participant Risk Management Plan describes treatments/actions in place or required to manage risks identified above.
- The participant and staff who work with the participant must be consulted; others should be consulted, as appropriate.
- The intake compliance officer completes the form.
- All steps must be completed - a new entry is made for every risk identified in IRP1.
Instructions for each column
1. Risk Category - indicate the level of risk being red, orange, yellow or green.
2. Risk - the actual/potential risk – refer to previous answers.
3. Conditions - relevant situations, triggers, indicators that might result in the risk behaviour – e.g. dust can lead to asthma, having to wait can lead to self-injuries behaviour or verbal or physical assault of others.
4. Person Responsible - who is to develop/implement management plan/guide/treatment action – Support Planner/Line Manager /Staff.
5. Due Date - the date that plan/guide/treatment action is due for development.
6. Date Implemented & reviewed - dates for implementation/review of plan/guide/treatment action.
7. Risk after control - identify the new risk rating after the implementation of controls.

Risk Management Plan

	Risk category	Risk	Conditions (situations, triggers)	Person Responsible	Due Date	Date Implemented & Reviewed	Risk after Control
1
2
3
4
5
6

Treatment plan
Refer to each risk listed above by number and explain the treatment/Management plan in place or to be developed

EMERGENCY PLAN

Contacts and Details for the Clients Emergency Plan, this will be sent to client.
Participant Emergency Contact Details
Contact 1*
Phone number*
Contact 2
Phone Number
Location / Vehicle
First Aid Kit Location
Assembly Point
Fire Assembly Point
Flood Assembly Point
Chemical Assembly Point
Physical Needs
Emotional Needs
Communication Needs
Other Needs

Client Support Plan
The support plan that you received by email has been developed for {clientsName}.

Please press the next button below to proceed to sign this if you agree with the plan that you received in your email.
Date of Next Review (Suggested at least 6 months out)

DayMonthYear
Date
Age
GP Name
GP Phone
Other Position Type
Other Name
Other Phone
Cultural Background
Language Spoken
Interpreter Required

Reason Client didn't participate in plan?
CLIENT'S STORY (Summary of the client's story so far)
ASSESSMENTS CONDUCTED (by Caring Lotus or others)

CURRENT SITUATION (immediate concerns)
CS immediate concerns
1st concern
2nd concern
3rd concern

Caring Lotus

Initial Client intake Form
Basic Demographic Information
Who is completing this form?*

Self/ClientClient RepresentativeReferrer
Full Name of Representative / Referrer
Name of person completing this form
Relationship to Client
Mother, father, Sister, Brother, Support Coordinator, Plan Manager etc.
Email of Representative / Referrer
example@example.com
Phone Number of Representative / Referrer
Client's Details
Full Clients Legal Name*
Preferred Name
Address*

Street Address

Street Address Line 2

SuburbState

Post Code
Email for client correspondence*
example@example.com
Phone Number for Client/Representative*
Best phone number to contact Client or responsible party
Date of Birth*

DayMonthYear
Date
How did you hear about us?
Person's name, Facebook, Instagram, Car Advertising etc
Gender
Language spoken at home
Interpreter Required

YesNo
Preferred communication?

EmailPostPhone

Funding details
Type of Funding*

Self ManagedPlan ManagedNDIA ManagedSelf Funded
NDIS Number
NDIS Budget
Do you have a budget you need to keep within?
New to NDIS?
NDIS Plan start date

MonthDayYear
Date
NDIS Plan expiry date

DayMonthYear
Email for Invoices to be sent to*
example@example.com
Services Required
Services Required from Caring Lotus
List type, frequency, estimated hours per week (will there be evenings, weekends, public holidays?)
Your Goals and Aspirations

We thrive on working with you on your Goals and Aspirations. Please let us know what you would like us to focus on with you in order of importance. You can also give us a timeframe in which you are hoping to achieve this. When working together, so many things are possible.
Please explain in your own words your goals and aspirations
What would you like us to work on with you to achieve?

ACKNOWLEDGEMENT PAGE
Disclaimer and Confirmation
Date Client/Representative Signed

DayMonthYear
Date
Intake Checklist

I have had the information on the Intake Checklist explained to me.
Client/Rep Intake Checklist Signature

Clear
Orientation Checklist

Caring Lotus has informed me of policies and procedures relevant to my support plan. I understand my rights and responsibilities during my time with Caring Lotus
Orientation Client/Rep Signature

Clear
Support Plan

I understand and agree to this Support Plan. I agree to my Support Plan being provided to the persons as listed above.
Support Plan Client/Rep Signature

Clear
Do you have any documents that you would like to upload?
Please upload any documentation you would like to share

eg. NDIS Plans, Behaviour support plans, Dr. or other service provider supporting documents etc.
Cancelof
Other Needs
Your Goals and Aspirations

We thrive on working with you on your Goals and Aspirations. Please let us know what you would like us to focus on with you in order of importance. You can also give us a timeframe in which you are hoping to achieve this. When working together, so many things are possible.
Client/Rep Consent Signature

Clear
Signature of Participant or Representative

Clear
Date Initial Intake Signed/Completed

DayMonthYear
Date
Should be Empty:

	Risk	Participant	Staff	Others	Source of Info
Startle reflex/sudden Body movements
Panic behaviour
Grabbing, holding, leaning
Tripping, running

	Risk	Participant	Staff	Others	Source of Info
Self harm / suicide risk
Cleanliness / OCD
Responsiveness
Friendliness
Alcohol/Drug Abuse
Financial responsibility
Fire Lighting - Arson
Smoker

	Risk	Participant	Staff	Others	Source of information
Dysphagia - choking at mealtimes
Choking - from positioning
Assistance with meals
Fractures, cuts
Bruising, abrasions
Seizures
Respiratory conditions
Allergies
Skin conditions
Diabetes
Sleep Disorders
Incontinence
Mental Illness
Eating Disorder

	Risk	Participant	Staff	Others	Source of information
Feeding
Toileting
Showering/bathing
Dressing/Undressing
Medications
Fire Evacuation

	Risk	Participant	Staff	Others	Source of information
Transfers
Mobility
Vehicle access
Moving in bed
Personal care tasks

FULL CLIENT INTAKE PACK

Consent Form

Client Intake Checklist

CLIENT ORIENTATION CHECKLIST

Individual Risk Profile

Risk Checklist

Risk Management Plan

EMERGENCY PLAN

Location / Vehicle

Assembly Point

Client Support Plan

DAILY LIVING - Self care

DAILY LIVING - Environmental

COMMUNITY ACCESS

MOBILITY & TRANSPORT

FAMILY RELATIONSHIPS & CONTACTS

CULTURAL & SPIRITUAL IDENTITY

HEALTH & MEDICAL

OTHER

Caring Lotus

Representative 1

Representative 2

ACKNOWLEDGEMENT PAGE

	Risk	Participant	Staff	Others	Source of information
Known history of violence
Previous assaults'/threats/verbal violence
Criminal record for violence or sexual assault
Reports from affiliated agencies/stakeholders
Use of firearms in the past
History of mental health issues
Substance abuse
The impact of the intervention causing stress or aggression in client
The occurrence of any incident in the client/family situation which could increase the risk to the employee’s safety

	Risk	Participant	Staff	Others	Source of information
Lost or unable to get home
Night
Follow signs / street names
Wear a watch comprehend time
Has a phone that works
Identification - Name, photo, address
Stranger Danger
Running Away
Traffic Awareness
Fears
Travel behaviour
Public Transport
Has Worker Name & Number

	Risk	Participant	Staff	Others	Source of information
Electrical
Sharps
Flammables, Poisons
Water hazard, bathing
Sun exposure
Traffic / roads
Travelling in vehicles
Slamming doors
Stove top
Oven
Kettle
Pets
High risk location
Safe Furniture
Property maintained
Toxic Chemicals or vapours
Uneven, slippery or steep surfaces
Housekeeping/clean/hoarding
Loose rugs/carpets
Inappropriate or poorly maintained floor or walking surfaces
Stairs or ramps
Guardrails or other suitable edge protection

	Name	Date	Conducted by	Date of Review
Assessment 1
Assessment 2
Assessment 3
Assessment 4

	Actions/Tasks	Client Responsibility	Others Responsibility	Frequency / Timeframes
PE 1
PE 2
PE 3

	Actions/Tasks	Client Responsibility	Others Responsibility	Frequency / Timeframes
LS 1
LS 2
Ls 3

	Actions/Tasks	Client Responsibility	Others Responsibility	Frequency / Timeframes
CA
CA 2
CA 3