AJH Intake Form

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Are you ready to make a referral for a specific participant to AJH for services?

Yes

Please complete our enquiry form if you are seeking information only and are not ready to provide specific participant details for a referral

Referral Form

Participant's First Name

Participant's Last Name

Participant's Address

Address Line 1

Address Line 2

City

State

Postcode

Participant's Date of Birth

Date

Participant's Contact Details

Mobile Phone Number

Home Phone Number

Preferred Method of Contact

Do you [does the participant] speak/use a language other than English as a first language (including non-spoken languages)?

Yes

Do you [does the participant] require an interpreter for appointments?

Yes

Which language?

Are you [is the participant] of Aboriginal or Torres Strait Islander origin? (select all that apply)

NDIS Number

NDIS Plan Start Date

NDIS Plan End Date

Do you [the participant] have any of the following? (Please select all that apply)

Formal Guardian

Informal Guardian

NDIS Plan Nominee

Not Applicable

Formal Guardian Contact Details

First Name

Last Name

Phone

Informal Guardian Contact Details

First Name

Last Name

Phone

Plan Nominee Contact Details

First Name

Last Name

Phone

Referrer Details

First Name

Last Name

Phone

Relationship to Participant

Please note with regards to Therapeutic Intervention - Our practitioners work remotely across SE QLD. Because of this we may not be able to offer face-to-face therapy. If we can't offer face-to-face intervention, is the participant willing to have ongoing therapeutic intervention via telehealth (e.g., Zoom)?

Yes

Please attach a copy of your NDIS Plan (Required for Support Coordination referrals but it's ok if you don't have it handy right now - you can send it to us by email intake@ajh.org.au later)

Please attach a copy of your NDIS Plan goals. (If you'd like to attach the whole plan, that's ok too). If you don't have it handy right now, you can send it to us by email intake@ajh.org.au later.

Budgets that the work will be paid from (please identify all budgets that will apply for the delivery of the work requested)

CoreCapacity Building - Improved Daily Living
Capacity Building - Improved Relationships
Capacity Building - Support CoordinationCapacity Building - Improved Health and WellbeingEarly Childhood Early InterventionCapacity Building - finding and keeping a job

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Participant	Plan Nominee	Informal Guardian
Formal Guardian	Support Coordinator	Other