ABTA Intake Form Interested in being supported by us? Please fill out the form below: Legal Name Preferred Name Pronouns DOB MM DD YYYY Phone * (###) ### #### Email * Address NDIS Number * Plan Dates Funding Type * Self Managed Plan Managed NDIA Managed Plan Manager or person responsible for payment * Where would you like your invoices to be sent? NDIS Recognised Disability * Other Disability Medical Information * Privacy Statement A Better Tomorrow Australia collect this information to ensure appropriate support is provided. Preferred Communication Method What supports are you requiring? * Support Coordination & Psychosocial Recovery Coaching Support Person Specialist Support Coordination What do you hope to get out of this support? Current Supports Date I would like to start being supported: * MM DD YYYY Person filling out: (if on behalf) Emergency Contact Details: Risk Assessment (for home visits) Do you live in an isolated or remote area? Yes No Is there reliable phone coverage at the property? Yes No Does anyone at the property have a history of violence or aggression? Yes No Does anyone at the property have a history of drug or alcohol misuse? Yes No Does anyone at the property have an infectious disease? Yes No Are there any firearms or weapons kept at the property? Yes No Are there any environmental hazards at the property (e.g. clutter, broken stairs) Yes No Are there any pets at the home? Yes No Parking instructions I consent to A Better Tomorrow Australia to taking photos and/or videos of me. I understand these images may be used for Social Media and Marketing purposes. Yes No I, * confirm all client details above to be correct and agree to receiving a service agreement from A Better Tomorrow Australia. * Person acting on behalf: Please fill out if you are acting on behalf of someone Where did you hear about us? Please let us know where you heard about A Better Tomorrow Australia Social Media Internet Search Engine eg. Google Friends or Family Community Board Other Thank you!
