Form21.

Participant Onboarding

Please complete this form so Keana Care can prepare your Service Agreement and arrange your community supports safely and according to your preferences. If a question does not apply, write N/A. Privacy note: only provide information relevant to your support — do not include Medicare details, bank details or your complete medical history.

0 of 15 required questions answered

Fields marked * are required.

PARTICIPANT DETAILS0/4

Full legal name

Preferred name

Date of birth

Date

Mobile number

Home address

Street addressStreet address line 2SuburbStatePostcode

Email address

NDIS PLAN DETAILS0/1

NDIS participant number

NDIS plan start date

NDIS plan end date

PLAN MANAGER DETAILS

Plan management company

Contact person if known

Invoice email address

Phone number if known

COMMUNITY SUPPORT PREFERENCES

Preferred support day and time

Number of support hours

Preferred start date

Date

Transport required during support

Activities or places you would like support to access

Relevant NDIS goal

EMERGENCY AND SAFETY INFORMATION0/3

Emergency contact name

Relationship to you

Contact number

Relevant allergies, health conditions, medications, mobility needs, communication preferences or safety information

CONSENT AND DECLARATION0/4

Please select Yes or No for each statement. You may change or withdraw your consent at any time by contacting Keana Care. If you would like help completing this form over the phone or in person, please contact us.

I consent to Keana Care collecting, securely storing and using this information to arrange and provide my supports.

I consent to Keana Care contacting my plan manager to confirm my funding and submit invoices.

I consent to Keana Care sharing relevant information with emergency services when necessary to protect my health or safety.

I confirm that the information provided in this form is correct.

SIGNATURE0/3

Participant or authorised representative name

Relationship or authority if signing for the participant

Signature

Sign with your mouse, or your finger on a phone or tablet.

Sign here using your mouse or finger

Date

Your form goes straight to the coordinator for review.