Participant Intake Form

1. Participant Details

What services you require from us?
MM slash DD slash YYYY
MM slash DD slash YYYY
Gender(Required)

Contact details

Interpreter required(Required)
Preferred option for communication(Required)
Do you identify as Aboriginal and Torres Strait Islander?(Required)
Residential Address(Required)
Is there a Guardianship and/or Administration order in place?(Required)

2. Disability / Medical Conditions

Disability / Medical Conditions including any diagnosis if relevant.

3. Funding

Funding Source(Required)

4. Preferences

5. Goals and Aspirations

I understand that:

How did you hear about us?(Required)
Information(Required)
Information(Required)
Information(Required)

Leave A Feedback

We appreciate you taking the time to provide us with feedback.

Feedback/Help Us Improve

We value feedback as we are constantly working to ensure we provide you with the best services possible. Is there something you need to tell us about your experience at uCare iCare. Please let us know and fill out the feedback form below.

Phone

1800 82 42 42 

Operating Hours

Monday-Sunday 8am – 7pm (24-hour support is also available)

If you are deaf or have a hearing or speech impairment

National Relay Service (NRS) makes it easier for you to contact uCare iCare.

Freecall 13 3677 (Voice and TTY) for all calls within Australia.

FreeCALL™ 1800 555 677 (Voice and TTY) for all calls within Australia to 1800 numbers.

For Non-English Speakers

Translating and Interpreting Service (TIS) National can provide telephone and onsite interpreters for non-English speakers to help you access uCare iCare.

Telephone

131 430

Feedback/Help Us Improve

Would you like us to follow up with you on your feedback?(Required)
Name(Required)