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Client Intake

Thank you for your response. ✨

First name(required)

Last name (required)

Email(required)

Phone number(required)

Date of birth:(required)

NDIS Number (if applicable)

Address

Guardian/Representative (if applicable)

Relationship to Participant

Phone number

Email

Are you NDIS funded?

Yes No

Plan type (if yes):

Self-managed Plan-managed NDIA-managed

Plan Manager and Support Coordinator (if applicable)

Primary diagnosis/support needs

Communication needs or preferences

Sensory considerations

Behavioural considerations

What services are you interested in?

Animal Therapy Respite Activites Individual Support

What are your goals for support?

Medical conditions we should be aware of?

Allergies?

Medications (if relevant)

Is there anything that may impact safety during activities?

Date you wish to commence (YYYY-MM-DD)

Emergency Contact – Name

Emergency Contact – Phone number

Emergency Contact – Email

Consent

I confirm that the information provided is accurate to the best of my knowledge I consent to Heart of Lorrimar Lodge collecting and storing this information for the purpose of providing services I understand that services will be tailored based on the information provided I consent to emergency medical assistance being sought if required I consent to photos/videos being taken for documentation/marketing purposes

By submitting this form, you consent to Heart of Lorrimar Lodge collecting and storing your information for the purpose of service delivery, planning, and communication. All information is handled in accordance with privacy and confidentiality requirements.

Name – Signature (typed)(required)

Date Submitted (YYYY-MM-DD)(required)

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Get Involved

Active and engaged residents build a strong community. Your participation makes a difference, whether you attend meetings, volunteer for events, or simply stay informed.

Joining our next meeting?

View Meeting Schedule

Have a question or concern?

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Contact

0413491305 hello@heartoflorrimarlodge.com.au
Maitland, NSW, Australia

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Healing happens in quiet moments and open spaces.

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