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Care Questionnaire

An NDIS-style intake questionnaire that support coordinators use to capture a participant's support needs, funding arrangements, health details, and personal preferences so they can be matched with the right care worker.

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Page 1

Participant Name

First Name

Last Name

Participant Preferred Name

Date of Birth

Address

Street Address

City

State / Province

ZIP / Postal Code

Phone Number

Gender

NDIS Number

Type of Supports Required (list multiple if required)

Personal Care Community Access Domestic Assistance Overnight Support Supported Independent Living (SIL) Transport

Section

Does the applicant have funding in your current plan specifically for SIL?

Yes No Not sure

Section

How is the participant's care currently managed?

Self-managed Plan-managed NDIA-managed Family/Informal Carers

Section

Page 2

Contact Name

First Name

Last Name

Relationship to applicant

Contact Email

Phone Number

Contact Mailing Address

Street Address

City

State / Province

ZIP / Postal Code

Preferred method of contact

Phone Email Mail

Page 3

Participant's Diagnosis (help us match you with the most suitable carer)

Participant Allergies

Participant Medications

Section

Do medications need to be taken on shift?

Yes No

Section

Communication Assistance Required?

Yes No

Care Management Specifics

Medication Administration Personal Hygiene Assistance Meal Preparation Behaviour Support Other

Page 4

About Me

Personal Goals

Interests

Tell us about your dislikes.

Other important things to note

Support Worker Preference Profile

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