NDIS PARTICIPANT INTAKE FORM This form must be completed first if the participant will be NDIS-funded for our services. Please fill out all areas with as much detail as possible so we can provide the best support possible. Participant Name * First Name Last Name Participant Date of Birth * MM DD YYYY Participant Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Approx Participant Height * We use this information to match the participant to the right horse. Approx Participant Weight * We use this information to match the participant to the right horse. Diagnosis/Disability: * NDIS Number * NDIS Management * Select one Plan Managed Self Managed NDIS line-item number and description * Primary Carer Information Name * First Name Last Name Email * Phone * Relationship to Participant * Does the participant(s) require medications during their visit? * Yes No I'd like to discuss this Information of person completing this form (Primary Carer, Support Coordinator etc) Name If different from above First Name Last Name Email If different from above Phone If different from above About the Participant Please tell us more about the Participants needs, including any behaviours of concern, Triggers and coping mechanisms. This will help us to best support them when they attend. * What are some of their likes/interests? * Please enter at least one goal/outcome for attending (or NDIS Goals) * Manager Details Case Manager or Support coordinator full name if applicable First Name Last Name Case Manager or Support Coordinator Email Required Support Level Select one 1:1 staff support required (HIGH) Group setting with 1:1 staff support (MEDIUM) Capable to Participate in a Group Setting with minimal support (LOW) Name of School (if attending) Media Permissons * Select where we can use media taken of the participant at SEC. Social Media Website Email Marketing Print Advertising None Any other information or requests? Thank you for submitting this enrollment form. We will be in contact shortly with more information about getting started with us.
