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Unity Care Support
Service Form
Name
Contact Number
Client's Date of Birth
NDIS Number/Reference Number
NDIS Plan Start Date
NDIS Plan End Date
Email
Client language and cultural background
How did you hear about Unity Care Support?
Google Search
Instagram
Through friends or family
Allied Health professional
Social Media/Online Advertisement
Please enlist client's medical condition and disability
Please enlist allergies/alerts
Is medication support required?
Yes, Medication administration is required
Yes, Requires assistance and prompting
No, Not required any support or assistance
Does the individual have any mobility issues/concerns?
Yes
No
Are there any behavioral concerns?
Yes
No
Are you a support coordinator
Yes
No
Who is the Service for?
Nursing Home
NDIS Participant
Aged Care Participant
TAC/Worksafe
Other
Client Address
Suburb
State
Post Code
Select the supports & services you are looking for
Community Nursing
Personalized Care
Community Access
Therapeutic Support
Other
Detail any other services expected under service agreement that contributes to your goals and independence
How often do you require services?
Once-off
Daily
Weekly
Fortnightly
Monthly
Yearly
Comments about support needs and schedules
Select date you wish to start services
Choose preferred timing for delivery of services
Anytime
Evening
24 Hour Service
Morning
All Day Service
Afternoon
All Night Service
Other
I consent to Unity Care Support handling and storing my information. Information about service users/clients will be kept confidential and accessed only as required by law. Clients' written and informed consent is necessary before sharing any information with third parties, including family members. This information will be used solely for providing quotations and service agreements. Personal client information must not be discussed outside the organization, and any discussions about clients must be appropriate and necessary.
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