Participant details
*
First Name
Last Name
Client's Date of Birth
*
MM
DD
YYYY
Gender
Male
Female
Transgender
Gender Neutral
Non-binary
Prefer Not to Say
Pronouns
Preferred Name
Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Phone
(###)
###
####
Mobile
(###)
###
####
Email
*
Language Spoken at Home
Interpreter required?
Yes
No
Preferred Method of Contact
Do you identify as Aboriginal and Torres Strait Islander?
Yes
No
Please select what services you wish to engage in:
If you have selected Other, Please specify what services you are interested in
NDIS Number
NDIS Funding Type
NDIS Managed (A copy of the NDIS plan MUST BE provided for NDIS managed participants)
Self Managed
Plan Managed
NDIS Plan Start Date
MM
DD
YYYY
NDIS Plan End Date
MM
DD
YYYY
Name of Self or Plan Manager
Email
Phone
(###)
###
####
Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Name
First Name
Last Name
Lives with the Participant
Relationship to the participant
Parent
If you have selected Other, please specify
Email
Phone
(###)
###
####
Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Preferred Method of Contact
Is the participants emergency contact the same as the participants representative?
If Yes, Please skip this section and continue to go to section 'About The Participant'
Living Situation
Types of disability
Religious/ cultural requirements
Does the participant need physical assistance equipment or support
Does the participant need assistive devices for communication
Is the participant visually impaired
Does the participant have any dietary requirements
Does the participant have any swallowing difficulties
Other considerations
General Information:
Provide us some general information about the participant our staff may need to be aware of. (I.e: like, dislikes, interesting facts, topics of choice etc.)
Does the participant have a current behavioural support plan?
Name
First Name
Last Name
Phone
(###)
###
####
Email
Organisation
Name
First Name
Last Name
Phone
(###)
###
####
Email
Practice
Name
First Name
Last Name
Phone
(###)
###
####
Email
Organisation
Type of Support Provided
If Other, Please Specify
Name
First Name
Last Name
Phone
(###)
###
####
Email
Organisation
Type of Support Provided
If Other, Please Specify
Name
First Name
Last Name
Phone
(###)
###
####
Email
Organisation
Type of Support Provided
If Other, Please Specify
Services you/The participant wishes to engage in
Here at Unique Traits Community Services, we have a wide range of services that our participants and patrons of the community can access. If you need further information about the services we provide please feel free to go to our services page and have a read-through. Alternatively, you can call us on 0455 245 409 to find our more information.
Short Term Goals
Long Term Goals
Where did you hear about us?
