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Book Your Sahara Services Program Today
Intake Form
Person Enquiring Details
Name:
Phone No
Relationship
Email
Reason for call
Program
Program
Communities Access
Plan Management
Support Coordination
Accommodation
General enquiry – what type of programs
Available places in specific program
Saturday Kids Group (fortnightly, school terms only)
School Holiday Program
Monday Social Group (weekly)
Wednesday Life Skills Group (weekly)
Thursday Girls’ Night Out (fortnightly)
Thursday Men’s’ Night Out (fortnightly)
Saturday group (weekly)
Sunday group (fortnightly)
Community Participation 1:1
Assistance with Daily Life 1:1
Untitled
Short Term Accommodation (STA)
Medium Term Accommodation (MTA)
Supported Independent Living (SIL)
Untitled
SIL Quote approved
SIL Eligible
Not SIL eligible yet
Personal Details of the Participant
Name
First
Last
Age
Gender
Primary disability
Please enter a number from
5
to
65
.
NDIS Funded
*
Yes
No
NDIS Participant Number
Level of support required
Low 1:3
Medium 1:2
High 1:1
Supporting documents available to support the need for service
NDIS plan/Goals
Medication
Occupational Therapy/(OT) Reports
Behavioral Support or Intervention Plan (BSP
Communication Plan
Epilepsy plan
Asthma Plan
Diabetes Plan
Health care plan
Mobility Plan
Nutrition and Swallowing plan
Mealtime and Fluids Management Plan
Other Available Management plan
Pre-existing Participant profiles or support documents. E.g. Person Centered Support Plans
When are you wanting to start the services
*
DD slash MM slash YYYY
Email
This field is for validation purposes and should be left unchanged.
