Intake form - Fearless Farm House

INTAKE - New Participant

This form must be completed first if the participant will be AGENCY or NDIS funded for our services. Please fill out all areas with as much detail as possible so we can provide the best support possible. Once this form is completed you can then continue to fill out any other relevant forms for our specific programs. Please fill out this form to start the booking process.

First Name (Participant)

Last Name (Participant)

Name of person completing this form (Primary Carer, Support Coordinator etc)

Participant Date of birth

Primary Carer relationship to Participant (e.g.Mum, Support Coordinator)

Primary Carer Phone Number

Primary Carer Email Address

Diagnosis/Disability:

Does the participant(s) require medications during their visit? (If Yes, a Medications form will be required and we will email this to you. Please ensure this is returned to us asap in advance of attending.)

Yes No

Please tell us more about the Participants needs, including any behaviours of concern, Triggers and coping mechanisms. This will help us to best support them when they attend. (What triggers them? How can we best support them when they are triggered? Do they have any specific behavioural areas we need to be aware of? If none, enter NIL.)

What are some of their likes/interests? (animals, arts & crafts, cooking, sense of humour, cars etc) [Providing this info will help ensure we can plan activities appropriately.]

Please enter at least one goal/outcome for attending FFH (or NDIS Goals) [E.g. Confidence building, Communication skills, Improved self-esteem etc. If none, enter NIL.]

Required Support Level:

1:1 staff support required (HIGH) Group setting with 1:1 staff support (MEDIUM) Capable to Participate in a Group Setting with minimal support (LOW)

Program you are interested in [Please tell us which FFH Program you are interested in. If more than one, you can include this in the 'additional comments' section at the end of this form.] :

Fearless Growth Day Program - Tailored to individuals Tuesday to Friday 10am-3pm [Only required to fill in this form] Fearless Farmers Day program - Group based Tuesday to Friday 10am-3pm [Only Required to fill in this form] Fearless Riders Program - Equine Supported Sessions Tuesdays & Thursdays 3.30pm-5.30pm [Please also fill out the 'Fearless Riders Form'] Afterschool Farmers Program- Tuesdays & Thursdays 3.30pm - 5.30pm [Only required to fill in this form] School Holiday Farmers Program [Please also fill out 'School Holiday Form'] Fearless Campers - Overnight Respite [Please also fill out 'Fearless Campers' form] Saturday Day Sessions - During Camp Weekends Therapeutic Support Sessions

Please provide dates & times requesting for the programs selected above

Address of Participant

Name of School if attending

Case Manager or Support coordinator full name if applicable:

Case Manager or Support Coordinator Email:

Case Manager or Support Coordinator Phone Number:

Can the Participant appear on Social Media? (Yes/No) [Please note that a waiver will be sent for signature on making a booking.]

Yes No

Allergies or Dietary requirements:

Any other relevant information or requests?