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CLINIC
- CLINIC APPOINTMENTS
- PELVIC PAIN CLINIC
TRAINING
FACTSHEETS
EDUCATION
MENOPAUSE
COUNSELLING
- UNPLANNED PREGNANCY COUNSELLING
- NDIS COUNSELLING
NDIS
NEWS
ABOUT
- JOIN
- DONATE
- COVID19
- EMPLOYMENT
- CONTACT US
- ANNUAL REPORT
- POLICIES
- EASY ENGLISH POLICIES

SHFPACT NDIS Activity Intake Form

YOUR DETAILS

First Name(*)

Please type your full name.

Last Name(*)

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Gender

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DOB(*)

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Address(*)

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Telephone(*)

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E-mail(*)

Invalid email address.

Preferred method of contact(*)

EmailPhoneTextOther Invalid Input

Tick as many as apply.

Are you a NDIS Client?(*)

YesNo Invalid Input

Living Arrangements (tick as many as apply)

FamilyIndependentSupported LivingOther Invalid Input

Who to contact if you need help?(*)

Invalid Input

Please supply, person's name, phone number, and relationship to the client.

Topics that are important to you(*)

RelationshipsPubertyMenstrual ManagementPublic, Private & Respectful BehaviourHealthy BodyMasturbationConsentPregnancy & ContraceptionSTI PreventionSafe SexCyber SafetyTransition to WorkRomantic relationshipsSoSAFE!FriendshipsOther Invalid Input

Any other topics that might be important to you.

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CLIENT INFORMATION : TELL US ABOUT YOU

I am good at(*)

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I like doing (*)

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I don't like(*)

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CLIENT SUPPORT NEEDS

Health and Wellbeing Needs(*)

Personal Care NeedsMobility AidsMental HealthDietary NeedsAllergiesDiabetesSeizuresOtherN/A Invalid Input

Tick as many as apply.

Other health & wellbeing needs, please specify.

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Learning needs(*)

Intellectual DisabilityASDADHDOtherN/A Invalid Input

Tick as many as apply.

Other learning needs, please specify.

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Sensory needs(*)

VisionHearingTactileOtherN/A Invalid Input

Tick as many as apply.

Other Sensory needs, please specify.

Invalid Input

Tick as many as apply.

Communication Needs (*)

InterpreterVisual SupportsCommunication DeviceOtherN/A Invalid Input

Tick as many as apply.

Other communication needs, please specify.

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Cultural Needs (*)

Religious PracticesDietary NeedsInterpreterOtherN/A Invalid Input

Tick as many as apply.

Other cultural needs, please specify.

Invalid Input

Behaviour Needs (*)

Inappropriate BehaviourWanderingPhysical AggressionVerbal Aggression OtherN/A Invalid Input

Tick as many as apply.

Other behaviour needs, please specify.

Invalid Input

Social Needs (*)

Support WorkerGroup SupportIndividual SupportOtherN/A Invalid Input

Tick as many as apply.

Other social needs, please specify.

Invalid Input

Other Support Services(*)

Occupational TherapistBehaviour Support PractitionerSpeech PathologistPsychologistOtherN/A Invalid Input

Tick as many as apply.

Other support services, please specify.

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Positive Behaviour Plan (*)

YesNo Invalid Input

What days are you available(*)

MondayTuesdayWednesdayThursdayFriday Invalid Input

Anything else you would like us to know?

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SHFPACT Policies in the Welcome Pack

Privacy & Confidentiality
Safety & Risk
Feedback & Complaints
Client Charter (rights & responsibilities)

Who provided this information?

Please choose one of the below:

A. Client

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B. Carer

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C. SHFPACT

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(*)

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Clinic

Level,1 28 University Avenue
Canberra ACT 2601
Australia

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SHFPACT Projects

SHLiRP
SoSafe! Program
Safe & Inclusive Schools ACT
Girl2Girl
Relationships and Sexuality Education Alliance
Sexuality and Ageing

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Sexual Health & Family Planning ACT is a health promotion charity (HPC) assisted with funding from the ACT Government. © SHFPACT 2022. Site designed by Lithium Innovation Pty Ltd.