Client Intake – Supporting Hands Care

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Start Your Care Journey Today

Complete our secure 4-step intake form to register as a client. Our care coordinator will personally review your details and contact you within 24 hours to discuss your personalised support plan.

100% Secure & Confidential

Response Within 24 Hours

NDIS & My Aged Care Registered

Free Initial Consultation

Participant Details

Medical & Safety

Cultural & Physical

Support & Lifestyle

1Step 1 of 4

Participant Details

Tell us about yourself so we can begin building your personalised care profile. All information is kept strictly confidential.

Personal Information

First Name * ⚠ First name is required

Last Name * ⚠ Last name is required

Preferred Name

Date of Birth * ⚠ Date of birth is required

Gender / Pronoun

Male Female Intersex / Indeterminate Prefer not to say Other

Preferred Gender

Preferred Pronoun

Aboriginal or Torres Strait Islander descent?

Yes No Prefer not to say

Residential Address

Street Address * ⚠ Street address is required

Suburb

State * ⚠ State is required

Postcode * ⚠ Postcode is required

Postal address same as residential

Postal Street

State

Postcode

Contact Details

Email * ⚠ Valid email is required

Mobile * ⚠ Mobile number is required

Home Phone

Service Type

NDIS Participant

I have an NDIS plan and would like to access funded disability supports.

My Aged Care

I am 65+ and have a Home Care Package or wish to access aged care services.

NDIS Number *

Funding Type

NDIS Plan Start Date

NDIS Plan End Date

Funding Details / Notes

Aged Care (AC) Number

My Aged Care Referral Code

Home Care Package Level

Funding Type

Services Required (select all that apply)

Personal Care & Daily Living

Domestic Assistance

Community Participation

Transport Assistance

Support Coordination

Supported Independent Living

Community Nursing Care

Counselling & Therapy

Capacity Building & Life Skills

Short-Term Accommodation / Respite

Group & Centre-Based Activities

Meal Preparation & Nutrition

Representative / Guardian (if applicable)

First Name

Last Name

Relationship to Participant

Phone / Mobile

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Medical Information & Safety

This information helps our team deliver safe, appropriate care and respond effectively in any situation.

Disability & Diagnosis

Disability / Condition Type(s) * ⚠ Please describe the disability or condition

Primary Disability Category

Physical Cognitive / Intellectual Sensory Psychosocial Autism (ASD) Multiple

Medication Information

Does the participant take any regular medications?

Yes No

List Medications, Dosage & Frequency

Known Allergies (medication or other)

Safety Considerations & OHS

Are there any known safety risks or behaviours of concern?

Yes — please specify No known risks

Describe Safety Risks / Behaviours of Concern

Is there a Behaviour Support Plan in place?

Yes No In progress

Are there any home or environment safety concerns?

Fall hazards Pet(s) present Narrow access Stairs / steps No handrails Hoisting required None known

Additional OHS / Risk Notes

GP & Medical Contacts

GP / Clinic Name

GP Surname

GP First Name

Clinic Phone

Clinic Address

Does the participant see any specialists?

Yes No

Specialist / Clinic Name

Specialty / Condition Treated

Phone

Address

Emergency Contact (Primary)

Contact Name * ⚠ Emergency contact name is required

Relationship * ⚠ Relationship is required

Mobile * ⚠ Mobile number is required

Home Phone

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3Step 3 of 4

Cultural, Communication & Physical Profile

Help us match you with the most appropriate carer and tailor our services to your cultural and communication preferences.

Cultural Background & Language

Country of Birth * ⚠ Country of birth is required

Years in Australia (if not born here)

Main Language Spoken at Home * ⚠ Home language is required

Other Languages Spoken

Is an interpreter required? *

Yes, I need an interpreter No, not required

Specify Language for Interpreter *

Are there cultural, communication, or intimacy considerations?

Yes — please specify None at this time

Cultural Values, Beliefs or Assumptions to Consider

Cultural Behaviours & Practices

Preferred Carer Gender

Written Communication / Literacy Level

Physical Profile (helps with identification & care planning)

Weight (kg)

Height (cm)

Build

Eye Colour

Hair Colour

Complexion

Distinguishing Features

Facial hair Birthmarks Tattoos Glasses Hearing aids Wheelchair user Walking aids None

Additional Physical / Identification Notes

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Support Arrangements & Lifestyle

Final details about your living situation, support network, and goals — so we can build the right care plan for you.

Living Arrangement

Current Living Situation * ⚠ Please select your living arrangement

Is there a pet in the home?

Yes No

Important People in the Participant's Life

Current Support Coordination

Do you currently have a Support Coordinator?

Yes No

Coordinator Name

Organisation

Phone

Goals & Aspirations

What are the participant's key goals? * ⚠ Please describe at least one goal

What does a good day look like for the participant?

What does the participant find most challenging?

Preferred Schedule

Preferred Days

Mon Tue Wed Thu Fri Sat Sun

Preferred Times

Morning Afternoon Evening Flexible

Approximate Hours of Support Per Week

Preferred Start Date

Additional Information

How did you hear about Supporting Hands Care?

Any other information you'd like us to know?

Consent & Declaration

I confirm that the information provided in this form is accurate and complete to the best of my knowledge. * I consent to Supporting Hands Care collecting, storing, and using this information to provide care services in accordance with the Australian Privacy Act 1988. * I understand that a care coordinator will contact me within 24 hours to discuss my support plan and answer any questions.

⚠ Please accept the required declarations to proceed

Step 4 of 4

Welcome to the Supporting Hands Family! 🎉

Thank you for completing your intake form. Your information has been securely received. A dedicated care coordinator will personally review your details and contact you within 24 hours to discuss your personalised care plan.

1Your intake form has been securely submitted

2A coordinator will review your details within 24 hours

3We'll call you to discuss your personalised support plan

4We match you with the perfect carer and begin services

Call Us Now Return to Home

Your Progress

Completion25%

Participant DetailsPersonal info, service type & contact

Medical & SafetyHealth info, medications & emergency contacts

Cultural & PhysicalLanguage, culture & physical profile

Support & LifestyleGoals, living arrangement & schedule

Need Help?

Call us on 1800 123 456 — available 24/7 to help you complete this form

Email us at info@supportinghandscare.com.au

Use the chat assistant below for instant answers to common intake questions

Your Privacy

All information you provide is encrypted, stored securely, and protected under the Australian Privacy Act 1988. We will never share your details with third parties without your explicit consent.

Quick Tips

Have your NDIS number or Aged Care referral code ready

Keep your GP's contact details handy

Fields marked * are required — all others are optional

You can complete this with a family member or support person

Intake Assistant

Here to help you complete the form