SHFPACT NDIS Activity Intake Form

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YOUR DETAILS

First Name(*)

Please type your full name.

Last Name(*)

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Gender

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DOB(*)

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Address(*)

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Telephone(*)

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E-mail(*)

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Preferred method of contact(*)

Preferred method of contact

EmailPhoneTextOther

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Tick as many as apply.

Are you a NDIS Client?(*)

Are you a NDIS Client?

YesNo

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Living Arrangements (tick as many as apply)

Living Arrangements (tick as many as apply)

FamilyIndependentSupported LivingOther

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Who to contact if you need help?(*)

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Please supply, person's name, phone number, and relationship to the client.

Topics that are important to you(*)

Topics that are important to you

RelationshipsPubertyMenstrual ManagementPublic, Private & Respectful BehaviourHealthy BodyMasturbationConsentPregnancy & ContraceptionSTI PreventionSafe SexCyber SafetyTransition to WorkRomantic relationshipsSoSAFE!FriendshipsOther

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Any other topics that might be important to you.

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CLIENT INFORMATION : TELL US ABOUT YOU

I am good at(*)

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I like doing (*)

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I don't like(*)

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CLIENT SUPPORT NEEDS

Health and Wellbeing Needs(*)

Health and Wellbeing Needs

Personal Care NeedsMobility AidsMental HealthDietary NeedsAllergiesDiabetesSeizuresOtherN/A

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Tick as many as apply.

Other health & wellbeing needs, please specify.

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Learning needs(*)

Learning needs

Intellectual DisabilityASDADHDOtherN/A

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Tick as many as apply.

Other learning needs, please specify.

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Sensory needs(*)

Sensory needs

VisionHearingTactileOtherN/A

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Tick as many as apply.

Other Sensory needs, please specify.

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Tick as many as apply.

Communication Needs (*)

Communication Needs

InterpreterVisual SupportsCommunication DeviceOtherN/A

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Tick as many as apply.

Other communication needs, please specify.

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Cultural Needs (*)

Cultural Needs

Religious PracticesDietary NeedsInterpreterOtherN/A

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Tick as many as apply.

Other cultural needs, please specify.

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Behaviour Needs (*)

Behaviour Needs

Inappropriate BehaviourWanderingPhysical AggressionVerbal Aggression OtherN/A

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Tick as many as apply.

Other behaviour needs, please specify.

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Social Needs (*)

Social Needs

Support WorkerGroup SupportIndividual SupportOtherN/A

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Tick as many as apply.

Other social needs, please specify.

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Other Support Services(*)

Other Support Services

Occupational TherapistBehaviour Support PractitionerSpeech PathologistPsychologistOtherN/A

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Tick as many as apply.

Other support services, please specify.

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Positive Behaviour Plan (*)

Positive Behaviour Plan

YesNo

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What days are you available(*)

What days are you available

MondayTuesdayWednesdayThursdayFriday

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Anything else you would like us to know?

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SHFPACT Policies in the Welcome Pack

• Privacy & Confidentiality
• Safety & Risk 
• Feedback & Complaints
• Client Charter (rights & responsibilities)

Who provided this information?

Please choose one of the below:

A. Client

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B. Carer

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C. SHFPACT

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(*)

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