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

Please note that all our day program activites have a fee associated to them . If the participant does not have an NDIS plan, Aspect can accept fee for service at NDIS rates.

Do you wish to proceed and pay from your own funds? *

YesNo

Thank you for your interest in our Adult Community Services program.

May we suggest contacting the following organisations:

Autism Connect www.amaze.org.au 1300 308 699
Disability Gateway www.disabilitygateway.gov.au 1800 643 787
NDIS www.ndis.gov.au/how-apply 1800 800 110

These sites are filled with valuable resources and have information and services that may help you find the support you need.

Please note we will keep all your information and we can easily retrieve your records. If you have further questions, please do not hesitate to call Aspect Customer Service1800 277 328.

NDIS Details (cont'd)

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?

This information is being collected for the purpose of determining service eligibility/provision and will be handled in accordance with Aspect’s Privacy of Personal Information and Data policy.

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

Save and Complete Later