Equity Thrive Pty Ltd

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Participant Intake Form

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Participant’s name
Identifies as
Phone details
Email
Interpreter Required
Preferred Option For Communication
Identifies as Aboriginal and Torres Strait Islander?
Name
Is There a Guardianship and/or Administration order in place?
Is There a Behaviour Management Plan in Place?

Provide the following information for participants under the age of 18, under guardianship or in the
care of family or caregivers.

Primary Carer?
Lives with Participant?
Emergency Contact?
Relationship to participant
Residential Address
Phone details
Checkboxes
Lives with Participant?
Emergency Contact?
Relationship to participant
Residential Address
Organisation Name
Organisation Name (copy)
Organisation Name (copy)
Organisation Name (copy) (copy)

Health Care Information

 

Medicare Number
Medicare Number (copy)
Medicare Number (copy) (copy)
Medicare Number (copy) (copy) (copy)
Medicare Number (copy) (copy) (copy) (copy)
Funding
Medicare Number (copy) (copy) (copy) (copy) (copy)
Checkboxes
Name

Personal Preferences

Preferred Name
Preferred Name (copy)
Preferred Name (copy) (copy)
When do you want to achieve your goals?

Participant Acknowledgment

I understand that:

• Equity Thrive Pty Ltd owns these records.

• Information within these records will be shared with other relevant workers within the
organisation only when the relevant worker requires the information to carry out their
duties and provide safe and quality services and support.

• I can ask to see my personal records at any time, and receive a copy for my records.

• My personal records are archived for a set period according to legislative and organisational policy requirements.

• I understand that all information obtained will be kept secure, private and confidential.
To the best of my knowledge, the information provided in this form is true and correct:

Participant’s Signature
Name of the Person Signing: (if not the participant)

Note: Authority to Act as an Advocate form is required if the individual signing this form is not the participant.