Referral Form — Integrity 4 Life

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Direct Support Services

Supported Independent Living

Independent Living Options

Short Term Accommodation

Positive Behaviour Support

Community of Practice

Direct Support Services

Supported Independent Living

Independent Living Options

Short Term Accommodation

Positive Behaviour Support

Community of Practice

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Folder: Services

Direct Support Services

Supported Independent Living

Independent Living Options

Short Term Accommodation

Positive Behaviour Support

Folder: Community

Community of Practice

PARTICIPANT INTAKE FORM

To refer yourself or someone you know to our services, please use this participant intake form.

Once we receive your enquiry, one of our team will be in contact shortly to discuss the next steps.

Name *

First Name

Last Name

Date of Birth (DOB) *

MM

DD

YYYY

NDIS Number *

Are you a Regional or Rural Participant?

Yes

No

Did someone else complete the intake form on the participants behalf? *

Name of Referrer *

Relationship to Participant *

Referrer Phone Number *

Referrer Email *

How did you hear about/ find I4L?

Primary Diagnosis *

Secondary Diagnosis (if relevant)

Participants current living situation

Does the participant identify as Aboriginal or Torres Strait Islander?

Does the participant need support to communicate? *

If you answered yes, please provide details.

Do you need an Interpreter? *

If yes, what is your preferred language?

Are you Culturally and Linguistically Diverse (CALD)? *

Intake officer has sighted NDIS plan and appropriate funding is present *

Does the participant have an active NDIS Plan? *

Plan End Date of current plan

MM

DD

YYYY

Intake Officer has sighted NDIS plan and confirms the appropriate funding is present *

How is your NDIS funding managed? *

Self Managed

Plan Managed

Agency Managed

If PLAN MANAGED, who is your Plan Manager?

What is your Plan Managers email address?

Do you have a Behaviour Support Plan (BSP)? *

If yes, are there any Restrictive Practices included?

Do you have any other Care Plans?

In what area's do you require support? Please list *

Will you need to take any medication while you are being supported by I4L? *

Do you take any medications? *

Do you have any known allergies? *

If yes, please provide details

Which of our unique services are you interested in? *

Support Coordination

Specialist Support Coordination

Direct Support Services

Supported Independent Living (SIL)

Independent Living Options (ILO)

Short Term Accommodation (STA)

In as much detail as possible, please describe the supports you would like Integrity4Life to assist you with. Please include times and days of the week (if possible) *

Please provide any other relevant information.

Thank you!

Telephone: 0427 628 214
Email: info@i4l.com.au

Emergency: 0428 580 156

39 Mitchell Street
Stockton, NSW, 2295

________

PO Box 141
Stockton, NSW, 2295

Opening Hours
Monday to Friday, 8am - 4:30pm

Our Services
Supported Independent Living
Direct Support Services
Short Term Accommodation
Independent Living Options Positive Behaviour Support

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ACKNOWLEDGEMENT

Integrity 4 Life acknowledges Aboriginal and Torres Strait Islander peoples as the First Peoples of Australia and we pay our respects to their elders past, present and future who we share this great region with.

DIVERSITY COMMITMENT

Integrity 4 Life is committed to embracing diversity and eliminating all forms of discrimination in the provision of health services. We welcome all people irrespective of ethnicity, lifestyle choice, faith, sexual orientation and gender identity.

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