Client Intake Assessment
Important note:- Inform client that they have a choice whether they want to provide the information being requested in this form. All information collected is used to provide the best possible service. If the client does not wish to provide the information requested 121 Care may not be able to provide services.Date of Assessment:
Assessed By:
Type of Funding:
Hours Per Week:
Sleepover Yes No nights/week
Previous Service Provider:
Contact Person:
Position:
Phone number:
Email:
Client details:
Name:
Date of Birth: Age: Gender F M Intersex
LGBTI Yes No N/A (Note: information used to match client with suitable workers)
Address:
Country and Place of Birth:
Telephone Home: Mobile:
Email: 121 Care Newsletter Yes No
Understanding of English: Very well Well Not Well
Speaking of English: Very well Well Not Well
Language/s:
Speech impairment:
Aboriginality: Aboriginal Torres Strait Islander Non Aboriginal Neither
Marital Status: Single Married De Facto Separated/Divorced
Current accommodation situation: Live alone Live with family members Other
Please specify:
Housing type:
Income: Disability Mobility Allowance Other
Public Trustee: Yes No
Contact Person: Tel:
Address:
Officeof the PublicGuardian: Yes No
Contact Person: Tel:
Address:
How does the client explain their circumstances/situations?
What informal support network does the client have? (e.g. – family, friends, neighbours)
Referral details:
Reffered By:
Reason for Referral:
Health and Medication Assessment:
Primary Disability:
Secondary Disability:
Medications Yes NoNeed supervision when taking medication Yes No
If yes request consent to get a GP summery of the medications Yes No
GP’s contact details:
Name:
Phone: Fax:
Practise:
Address:
Take medication independently (no need for assistance from worker) Yes No
(No need for a GP summery)
Medication Indemnity Form completed Yes No
Do you have an Epipen/Anapen (Anaphylactic response) Yes No
Medication Type / Quantity / Reason
Vision Hearing Oral Diet
Normal Normal Own teeth Diabetic
Glasses Aids Dentures Soft
Impaired Mild loss Normal ¨ Peg
Blind Severe loss Peg
Special
Cognitive Assessment:
Fully alert Sometimes confused At risk due to mental state Confused but safe
Note any concerns:
Assistance required Assessment:
Tasks / Done By Self / Done by Family / Done by AgencyDental hygiene
Bathing /showering
Feeding
Toileting
Enemas
Shaving
Manicure
Dressing
Cooking/meal prep.
Cleaning
Laundry
Shopping
Chair/bed transfers
Wheelchair dependence
Vehicle Information:
Do you own a vehicle? Yes NoCopy of vehicle registration Yes No
Will workers drive your vehicle? Yes No
Hobbies/Interests: (Outings, respite, day program, etc.)
Further observations:
Client’s preference of workers: (female, male, quiet or outgoing etc.)
Consent from Client:
Verbal consent has been given by the client to seek further information or to discuss client with other agencies? Yes No
Date:
Office Staff Representative:
(Note:- Written consent form will be completed with client as part of their Service Agreement)
Wellness Assessment:
Is there self-neglect or abuse? Yes No
Is the client eating well? Yes No
Is Emergency Alarm service required? Yes No
Is Fire Procedure (Safe Home Assessment) required? Yes No
Special Requirements:
Referral details identified:
Emergency Procedures document completed Yes No
Home Assessment completed Yes No
Consent to book a Risk Assessment for all transfer tasks Yes No
(With an O.T./Physio, check if the client has a risk assessment from earlier provider and can provide a copy to the organisation, no older than 3 years.)
Assessor checklist:
Client/Family member or Carer has been informed of/provided with:
The purpose of the assessment.
Referral(s) and proposed actions agreed by client.
A copy of this Client Initial Service Assessment.
Signature of Assessor / Name and Position of Assessor / Date
Roster Week One
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Total Hours Week one
Total Sleepovers Week One
Roster Week One
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Total Hours Week one
Total Sleepovers Week One
Client Emergency Procedures
Client’s Name:
Personal details:
D.O.B:
Funding Type:
BIS no:
Disability:
Address:
Mob/Tel
Email:
Emergency Procedures:
v Call “000” and after that notify Service User’s family.
v If it’s not an emergency please call the Non Urgent Ambulance Number: 131 233
v Poisons helpline: 13 11 26
Family Details:
Family Phone(s) Notes
Workers:
Workers Phone(s) Email
Ø Office T: 5443 9777
Ø Case Manager M: 0408 439 480
Ø Kym Chomley, Manager M: 0418 447 771
Emergency Services Staff (Last Option):
Services Phone(s) Contact
Other Services:
Services Phone(s) Contact/notes
Action Plan
Actions required by Case Manager:
Actions taken by Case Manager:
Completed: □ Yes □ No
Completed by:
Completion Date:
11