YLOT Daily Living and Community Access Intake & Support Form

Participant's Name: *

First

Last

Preferred Name:

Date of Birth: *

Gender: *

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Mobile Number:

Email address:

Country of Birth:

Religion:

Aboriginal or Torres Strait Islander? *

Refugee or Asylum Seeker? *

Refugee
Asylum Seeker
Neither
Prefer not to say

Primary Carer:

Name: *

First

Last

Relationship to participant: *

Are you also the Participant's Representative: *

Yes
No

Phone Number: *

Email: *

Address: *

Shared Living Arrangements

Please note any shared living arrangements here: (eg. Mum's house, Dad's house, respite, etc)

Participant's School (if applicable):

Class & Teachers Name:

Funding Information

NDIS Number: *

Start date of NDIS Plan: *

End date of NDIS Plan: *

NDIS plan type: *

Self Managed
Plan Managed
NDIA Managed (Unfortunately we cannot accept participants in this category at this time)

Please indicate which NDIS Plan category to charge your child's fees: *

Plan Manager: (if applicable)

First

Last

Plan Manager Email:

Plan Manager Phone Number:

Support Coordinator: (if applicable)

First

Last

Support Coordinator Email:

Support Coordinator Phone Number:

Is this a transition from another service provider: *

Yes
No

Former Service Provider

Contact Number:

Email Address:

Representative Name:

Reasons for the transition:

Emergency Contact 1

Name: *

First

Last

Relationship: *

Phone Number: *

Email Address: *

Address: *

Emergency Contact 2

Name:

First

Last

Relationship:

Phone Number:

Email address:

Address:

Support Requirements:

Required days and times (please list days of the week, times of day, and frequency if known) as well as any other shift requirements: *

Please be as detailed as possible. (eg Saturday fortnightly 10am-2pm - in-home support, and every Wednesday 9am-3pm - community access and therapy visit) this will help us in matching a suitably qualified and available staff person.

Participant uses a wheelchair: *

Yes
No
Sometimes

Participant has a behaviour management plan: *

Yes
No

Participant has 'regulated restrictive practices' authorised in an NDIS approved behaviour management support plan *

Yes
No

If yes, as an unregistered NDIS provider, YLOT are unable to enforce regulated restrictive practices. Please contact us to discuss further.

Participant has a meal management plan: *

Yes
No

Participant has a medical action plan (eg Asthma, seizure management, etc): *

Yes
No

Participant has an Individual Education Plan (IEP) or Learning Plan (LP) at school: *

Yes
No

Participant has a manual handling plan: *

Yes
No

Please attach copy of plans here, if you have them:

Drag & Drop Files, Choose Files to Upload

Please list any allergies: *

Please list any medications taken during the day (note If the participant needs medication administered by YLOT you will need to provide us with a signed medication chart from the GP):

Does your young person need a personal emergency and disaster management plan? For example do they have mobility concerns, do alarms cause them to become heightened and dysregulated. . If yes, please list:

Please list any additional health info: (eg. relevant medical conditions, falls risks & any triggers)

Participant Profile

To enable our staff to best meet the participants needs and interests, we ask that you complete the following questions for us to be able to create a Profile for staff to assist in planning for the participant.

Please attach a photo

Drag & Drop Files, Choose Files to Upload

What is important to the participant?

What do people like and admire about the participant?

What does the participant like doing? What are their interests?

Things the participant doesn’t like:

How does the participant communicate? If non-verbal, please list AAC device/visuals etc:

How can we best support the participant (including toileting information):

Please give any other information that will enable us to best support the participant:

Does the participant have any goals that we can work towards:

Media Consent

We love taking photos of our young people having fun. Please let us know your preferences regarding photos and videos of the participant: *

Yes, I consent to my child being photographed and/or filmed, and for these images/videos to be shared on our social media and website.
No, I do not consent to any media of my child being taken or shared.
No media for publishing, but I would like to see photos of my child privately (e.g., shared directly with me but not posted publicly).

NOTE: Photos will be taken and shared occasionally, but not necessarily every day.

Declaration *

By ticking this box and signing below, I acknowledge and agree with this Declaration.

I acknowledge that: • These records will be managed by YOUNG LEADERS OF TASMANIA (YLOT) only. • Information within these records will be shared with specific staff members within the organisation to allow them to carry out the intake assessment. • If the participant is offered YLOT's services and they accept, this information will also be used to carry out the initial assessment and for service planning, development and delivery. • The participant and their representative can ask to see the records and receive a copy. • Records are archived for a set period according to Privacy and Confidentiality Policy and Procedure. • All information obtained will be kept confidential. • This information will be used to set up the Service Agreement with YLOT and the Participant Assessment and Support Plan if the participant is offered YLOT's services and they accept. • A signed Service Agreement is required to start receiving YLOT's supports and services. • A Service Agreement will be sent to the participant for signing prior to the appointment of the initial assessment. This is a legal requirement by NDIS. • The Service Agreement is signed off by both the participant and/or their representative and YLOT. I confirm that: • I understand I can get further information about how YLOT handles my personal information from the Privacy and Confidentiality Policy and a copy of this policy. • I understand I can withdraw or change my consent to share information and/or my permission for a third party to act on my behalf at any time. • I confirm the information provided in this form is complete and correct. • I give my consent to YLOT to use the participant’s information for the purposes outlined above. • I understand giving false or misleading information is a serious offence. • I understand this information is protected by law and can only be given to someone else where Commonwealth law allows or requires it or where I give permission. You can find out more about how we collect, use and disclose your personal and sensitive information on our Privacy and Confidentiality Policy.

Signed (Type name) *

Date: *

Thank you for completing this registration form. A YLOT representative will be in contact via email or phone in the coming weeks to discuss your application further.