Adult Community Services Intake Form

Welcome to Aspect Adult Community Services

Once we have received this completed form, our Adult Community Service team will contact you within 10 days to assess your support network, your main priorities and how we might be able to assist with your goals. We can then organise a time to visit one of our centres in Sydney or Melbourne.

If you any questions regarding this form, please call us on: 1800 277 328 or email: customerservice@aspect.org.au

Participant Details - the person who will receive the supports

Participant First Name *

Participant Last Name *

Email *

Mobile *

Date of Birth *

Gender *

FemaleMaleTheyOther

Please indicate preferred pronouns

If other, please indicate gender *

Street Address Line 1 *

Street Address Line 2

City *

State *

Post Code *

Country of Birth *

Please specify *

NDIS Details

Information about our current Adult Community Service fees is available HERE

Does the participant have an Autism diagnosis (by a health professional or self-diagnosis)? *

YesNoAwaiting assessment/diagnosis

Does the participant have an NDIS plan ? *

YesNoWe are applying for the NDIS

If the participant does not have an NDIS plan, Aspect can accept fee for service at NDIS rates.

NDIS Client Number: *

NDIS Plan Start Date *

NDIS Plan Expiry Date *

How is your plan managed? *

Self ManagedPlan ManagedAgency Managed

Please provide the name of the provider *

Aspect Adult Community Centres

Our centres in Sydney and Melbourne offer a range of individualised programs and supports.

They are open Monday to Friday from 9am to 3pm. You can find out more about our locations HERE

What types of skills are you looking to develop? (You can choose more that one) *

Please list other skill(s) *

What activities are you interested in? (you can select more than one) *

Active programs (gym, swimming, walking, yoga, sports, travel etc.) Domestic programs (cooking, gardening, cleaning, shopping) Social programs (board games, trivia, podcasting, newsletter) Other

Please list any other(s) *

Are there any other practitioners involved in the participant's support? *

Please list other supports *

Please select an Adult Community Services location *

Enquirer Details

Who is completing this form? *

I am the participantI am enquiring on behalf of the participant

Enquirer First Name *

Enquirer Last Name *

Enquirer email *

Enquirer mobile number *

Relationship *

Please specify relationship to participant *

Who is the best person to contact? *

ParticipantEnquirer (the person completing this form)Other (please specify below)

Contact's first name *

Contact's last name *

Contact's email *

Contact's mobile number *

What is the contact's relationship to the participant? *

Participant Living Arrangements

Living Arrangements *

If other, please specify *

What languages are spoken at home? *

Is an interpreter required? *

YesNo

Do they identify as Aboriginal or Torres Strait Islander? *

YesNo

Who makes the decisions for this participant? *

I make my own decisionsSomeone helps the participantThere is a Legal Guardian in place

Decision Maker Full Name *

Decision Maker Email *

Decision Maker Contact Number *

Is there anything else you think we should know?

By ticking this, I confirm that all information supplied at the time of completion is accurate *

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