Wara Yindi Support Services Intake Form

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Welcome to Wara Yindi Support Services

Thank you for taking the time to complete our Referral & Intake Form.This form helps us get to know the person being referred, understand what is important to them, and ensure we can provide safe, personalised and culturally responsive supports from the very beginning. Please complete this form to the best of your knowledge and ability. The more information you can provide, the better we can understand the participant's strengths, goals, routines, support needs and preferences before we begin working together. If you are unsure of an answer, you are welcome to leave it blank or write "N/A" (Not Applicable) where appropriate. We understand that you may not have all the information available, and our team can discuss any missing details with you during the intake process.

The information you provide will assist Wara Yindi to:

• Develop a personalised support plan.

• Identify any immediate support or safety considerations.

• Coordinate services and referrals.

• Prepare for intake, implementation and planning meetings.

• Match participants with the most suitable staff and supports.

Thank you for helping us get to know the participant. We look forward to working with you.

About you

Your Name *

Organisation (if applicable)

Relationship to Participant *

Has the participant (or their representative) consented to this referral? *

YesNo

Contact Number *

Contact Email *

Preferred Contact Method *

EmailPhone

Wara Yindi Support Services Intake Form

About the participant

Participant Name *

Participant Date of Birth *

Address *

Contact Number *

Contact Email *

Preferred Contact method *

EmailPhone

Does the participant identify as Aboriginal and/or Torres Strait Islander *

AboriginalTorres Strait IslanderBothNeitherPrefer not to say

Interpreter required *

YesNo

Communication or accessibility Needs *

Wara Yindi Support Services Intake Form

NDIS Information

Does the participant currently have an NDIS Plan? *

YesNo

NDIS Details

NDIS Start Date *

NDIS End Date *

NDIS Number *

Plan Management

NDIA managedPlan ManagedSelf Managed

Plan Manager Name *

Email *

Current NDIS Goals *

Wara Yindi Support Services Intake Form

Reason For Referral

Why are you referring to Wara Yindi Support Services

Click all that apply *

Support CoordinationSpecialist Support CoordinationSupport WorkGroup ProgramsParent & Carer TrainingMentoringCommunity ProgramsAssessments Other

Please specify

Tell us about the Support You are Looking For

Is there anything you would like Wara Yindi to do as a priority?

Wara Yindi Support Services Intake Form

About the Participant

What is important to the participant *

What are their strengths? *

What do they enjoy doing? *

Wara Yindi Support Services Intake Form

Daily Life

Describe a typical day *

What helps their day go well? *

What can make their day difficult? *

Wara Yindi Support Services Intake Form

Current Supports

Who currently supports the Participant?

Click all that apply *

GPChildcare / Kindy / SchoolEmployment specialists (Speech, OT, Ect)Support Coordinatorsupport WorkerSporting clubsCommunity Groups Other

Please specify

Please give Name and Contact details for all supports you stated above *

Wara Yindi Support Services Intake Form

Current gaps in supports

What supports are not in place yet that would make the biggest difference? *

Wara Yindi Support Services Intake Form

Medication and Health

Does the Participant take medication *

YesNo

Does the Participant have any allergies? If yes, what? *

Does the participant have any health conditions? *

Is there anything else the staff should know to support the participant? *

Wara Yindi Support Services Intake Form

Medication Details

Medication Name, Dose, who administers? *

Wara Yindi Support Services Intake Form

The Participants family and household details

Who lives in the home? *

Family Strengths *

Current family challenges *

Pets in the home? *

Wara Yindi Support Services Intake Form

Safety and Wellbeing

Is there anything happening at the moment that is affecting the participant's wellbeing or making life more difficult? *

Are there any situations where extra support would be helpful? *

HousingTransportMental HealthBehaviourSchoolFamily StressOther

Please specify

Is there anything you would like Wara Yindi to know about the Participants Safety? *

What helps the Participant feel calm, safe and supported? *

Does the Participant have any of the following? *

Behaviour Support PlanSafety PlanEmergency PlanMedication PlanRisk AssessmentSchool Plan / One planOther

Please specify

Anything else we should know? *

Wara Yindi Support Services Intake Form

Documents

Please email any relevant documents to Intake@warayindi.com.au (e.g., NDIS Plan, Assessments, Reports, Safety Plans, etc.) *

I have emailed my documentsI have no documents to email

Have you read and reviewed our Participant Handbook Available on our website - www.warayindi.com.au *

YesNo, can I have it emailed to me.

Wara Yindi Support Services Intake Form

Consent

I confirm that the information provided is true and correct to the best of my knowledge. *

YesNo

I consent to Wara Yindi collecting and storing this information for the purpose of providing supports. *

YesNo

I understand and consent to Wara Yindi using secure AI-assisted tools to support administrative tasks related to my referral and service delivery, in accordance with privacy and confidentiality requirements. *

YesNo

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