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Mill Valley Ranch
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Home
About
FAQ
Services
Activities
Assistance with daily life
Community Access
Finding / Keeping a job
High Intensity Support
Behaviour and Family Coaching
Request Care
Camps
Illuka
Mill Valley Ranch
Benefits Of Camp Life
What to Bring
Policies
Privacy Statement
Participant Handbook
Child Safety and Wellbeing policy
Rights and Responsibilities
Participant Incident Management
Complaints Policy
Gallery
Contact Us
Join Our Team
Staff Portal
New Client Intake Form
New Client Intake Form
Please enable JavaScript in your browser to complete this form.
Please enable JavaScript in your browser to complete this form.
Carer or Participant Representative First Name
*
Carer or Participant Representative Preferred Name (if different)
*
Carer or Participant Representative Last Name
*
Relationship to Participant
*
Parent
Legal Guardian
Primary Carer
Family Member
Case Manager
Other
if other, please describe
Phone No
*
Email
*
Preferred contact method
*
Email
Phone
managed, Name Name
Participant Preferred Name (if different)
*
Participant Last Name
*
Participant Address
*
Customer Suburb
*
State
*
ACT
NSW
QLD
SA
VIC
WA
Customer Postcode
*
Date of Birth
*
Format: dd/mm/yyyy
Participant Phone No
Participant Email
*
Participant Preferred Contact Method
Email
Phone
Gender
Male
Female
Language spoken at home
Living Situation
Own home
Own home / Living with family
Rent home
Rent home / Living with family
Live with parents / family
Support accommodation
Self managed, Plan managed or NDIA managed
Self managed
Plan managed
NDIA managed
NDIS number
Plan Details
Self managed
Portal managed
Plan management provider
Other
Plan management provider details
Disability diagnosis and severity / medical conditions / other necessary health information
Services Required
Assistance with Self Care Activities
Community, Social and Recreation Access
Employment Support
Respite / Short Term Accommodation
Personal care - assistance required with:
Showering / bathing
Toileting
Dressing
Grooming
Bowel care (Enemas/Suppositories)
Leg bag care
PEG feeding
Wound care
Other
Mobility - assistance required with
Walking - independent
Walking - assisted
Walking frame
Walking stick
Wheelchair - electric
Wheelchair - manual
Hoise transfers
Shower chair
Other
Communication
Verbal
Non-verbal
Communication Aid
Other
Cognition
Very good
Good
Fair
Poor
Behavioural support plan?
Yes
No
In the process
If yes, please describe behaviours / behavioural plan
Do you require specific shift times?
If so, please mention
Do you have any Support Worker preferences?
Age, gender, interests, attributes, etc.
Do you have any short / long term goals?
Please list
Is there anything else we should know?
Submit
At CWSS we bring people with all abilities together through fun, friendships, and inclusion.
NDIS Registration # 4050 159 833
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