INTAKE ASSESSMENT FORM

  • INTAKE ASSESSMENT FORM

    Complete this comprehensive assessment form. All fields are optional unless the original document says otherwise. Preserve the original order as closely as possible.

  • CLIENT DETAILS

  • Date of Birth*
     - -
  • Format: (000) 000-0000.
  • Gender
  • Preferred Method of Correspondence

  • REPRESENTATIVE/ADVOCATE DETAILS

  • Format: (000) 000-0000.

  • EMERGENCY CONTACT #1

  • Format: (000) 000-0000.

  • EMERGENCY CONTACT #2

  • Format: (000) 000-0000.

  • POWER OF ATTORNEY

  • Format: (000) 000-0000.
  • Paperwork

  • ENDURING GUARDIAN

  • Format: (000) 000-0000.
  • Paperwork

  • HEALTH AND MEDICAL

  • Full pension
  • DVA entitlements
  • Income tested fee required/advised
  • Format: (000) 000-0000.

  • MEDICAL HISTORY

  • HEALTH RISKS

  • Allergies
  • Health Risks:
  • COGNITIVE MENTAL STATE

  • ADVANCED CARE DIRECTIVE

  • Does the client have an Advanced Care Directive in place?
  • If yes, do they have a copy on hand?

  • MOBILITY

  • Are handrails in place?
  • OT assessment has been completed

  • COMMUNICATION

    Client abilities
  • Hearing
  • Vision
  • Speech difficulty/impairment
  • Language other than English
  • Equipment/aides required

  • FAMILY OR COMMUNITY SUPPORTS

  • HOME ACCESS

  • Parking at premises
  • Is access to entry point safe and clear of obstacles?
  • Is there a clear exit available in the event of a fire?

  • HOME SAFETY

  • Does the service user have pets?
  • If any mats are present, are they safe and secure?
  • If any indoor steps are present, are they safe?
  • Are passageways and hallways clear of obstructions?
  • Is the service user/carer in the home a smoker?
  • Is the smoke alarm in working order?
  • Smoke alarm management
  • Are the light switches visible?
  • Is there enough natural/electrical lighting available?
  • Are there extension cords or cords to electrical equipment causing a trip hazard?
  • Emergency readiness - consent to ask questions

  • EMERGENCY READINESS CHECKLIST

  • We will be working with emergency services to improve the emergency readiness of our clients and want to check that you have information about some key things to help you be prepared in case of home fires, bushfires, floods, storms or other emergencies.

    Are you happy for me to ask a few questions about this?

  • Is the house in a bush fire or flood-prone area?

  • Staff can check for bush fire prone areas with this link - https://www.rfs.nsw.gov.au/plan-and-prepare/building-in-a-bush-fire-area/planning-for-bush-fire-protection/bush-fire-prone-land/check-bfpl 

  • How prepared are you to act in an emergency?
    Preparing for an emergency is about preparing the things you will need (an emergency kit), preparing your home and thinking about what you will do in an emergency. (e.g. who will you call, how will you get out, where will you go) this includes thinking about pets.

  • Do you have an emergency kit together?

  • How can we assist in an emergency?

    • Notify a specific contact person:

  • Format: (000) 000-0000.

  • SERVICE PLAN

  • Tasks indicated with a tick are to be performed each occasion of service.

  • SOCIAL SUPPORT

  • Shopping

  • Will you be buying cigarettes or alcohol?

  • Appointments

  • Workers cannot relay medical information to Linked to Life.

  • Outings/Activities

  • Home Visit

    Reason for visit:

  • Social Support Specifications

  • Day:

  • Time:

  • Commencement date:
     - -

  • Payment method: Direct debit

     

  • DOMESTIC ASSISTANCE

  • Laundering
  • Is the washing equipment safe and in good working order?
  • Is the access to clothesline safe and easily accessible for worker?
  • Is there a clothes basket/trolley?
  • Is the bedroom/s accessible with sufficient movement space around the bed?

  • Kitchen Area

  • Bathroom Toilet Areas

  • Bathroom 1:
  • Bathroom 2:
  • Is the bathroom/wet and other areas safe/accessible for worker?
  • Are areas well-lit and ventilated?

  • Bedrooms

  • Lounge/dining/entry/hallway(s)

  • Vacuuming

  • Is there an appropriate vacuum available and in working order?

  • Mopping

  • Is the equipment/products appropriate for the job?

  • Hand-wringing mop cannot be used.

  • Is the mop bucket appropriate?

  • Heavy metal buckets cannot be used.

  • Optional or Occasional Tasks (when time allows)

  • Domestic Assistance Specifications

  • Day:

  • Time:

  • Commencement date:
     - -

  • Payment method: Direct Debit

  • PERSONAL CARE

  • Showering/personal needs

  • Compression stockings - need assistance?
  • Pressure stockings - need assistance?

  • Continence

  • Allied Health (podiatry/physio/OT etc.)

  • Medication needs

  • MEALS

  • Meal status
  • Delivered Meals
  • Meal Management Plan in place

  • MAINTAINING THE HOME ENVIRONMENT

  • Lawn and garden care
  • Tasks to be completed:
  • Client has assistance with lawn mowing.
  • Format: (000) 000-0000.
  • Client has assistance with gardening.
  • Format: (000) 000-0000.

  • General home maintenance

  • Client requires assistance with:

  • Home Environment Specifications

  • Preferred day of service:
  • Commencement date:
     - -

  • Payment method: Direct Debit

  • SUMMARY OF ACTIONS

    (e.g. referral, liaison with other providers, seek community links, equipment provisions etc.)

  • CORRECTIVE ACTION REQUIRED

  • Date
     - -
  • Date
     - -
  • Should be Empty: