New Participant Questionnaire - United Abilities Spam protection, skip this field Name Date MonthJanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember Day12345678910111213141516171819202122232425262728293031 Year1920192119221923192419251926192719281929193019311932193319341935193619371938193919401941194219431944194519461947194819491950195119521953195419551956195719581959196019611962196319641965196619671968196919701971197219731974197519761977197819791980198119821983198419851986198719881989199019911992199319941995199619971998199920002001200220032004200520062007200820092010201120122013201420152016201720182019202020212022202320242025202620272028202920302031203220332034203520362037203820392040 What activities/hobbies do you currently do? Comments (optional) What activities/hobbies would you like to try? Comments (optional) Do you drive/have your own car? Yes No Other Comments (optional) Do you use public transport? Yes No Other Comments (optional) If not, would you like support to help access public transport? Yes No N/A Other Comments (optional) Do you have anything that you are allergic to. e.g. medicines or food etc? Yes No Other Please explain Comments (optional) Do you need to take medication and if so what is this for? Yes No Other Comments (optional) Do you manage this yourself or do you need support with this? To confirm eligibility to use our services, are you happy to disclose the nature of your disability? Who would be the main contact person for you? What is their relationship to you and their phone/email? Comments (optional) Are you comfortable being around groups of people and noise or do you prefer quieter environments? Yes No Other Comments (optional) Confirm: Easy access to home (live alone/others, parking, front/back access, dogs to be aware of etc) Comments (optional) Do you have a copy of your NDIS plan that you are happy to share with us (or provide date plan ends and any particular goals etc)? Comments (optional) Are there any physical health or mental health risks we need to be aware of? Would you like a meet and greet with your allocated support worker before your first support session?
