Participant Intake Form Participant Details Given Name(s) Surname Preferred Name Date of Birth Residential Address Details Postal Address Details If the same as the Residential Address Details — write - “As Above” Email Address Phone Number How do you describe your gender? MaleFemaleAnother term (please specify) Are you an Aboriginal or Torres Strait Island descent? NoYes - Aboriginal Only Yes - Torres Strait Island OnlyYes- Both Language/s Spoken at home Interpreter needed? YesNo Communication Method/Style? VerbalNon-verbalWritten VisualSign LanguageCommunication Devices Preferences for communication EmailPhoneSMSPost Disability Conditions/Disability type(s) including diagnosis Is there Office of the Public Guardian order in place YesNo Name Phone Email Is there Public Trustee order in place yesNo Name Phone Email Details - Next of Kin/ Emergency Contact (If applicable) Name Relationship with the participant Address Phone Email NDIS Information NDIS Start Date NDIS End Date NDIS Funding Type Plan-managedSelf-managedNDIA-managed