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)

Make a Referral

Enabling outcomes to achieve your goals

We have a strong commitment to Customer-focus

Our purpose is about supporting individuals to achieve their goals, following their dreams, respecting their choices whilst also protecting their rights. We recognise that everyone is unique. We design our disability support services in close consultation with our customers – so that we can support them in doing things that matter to them most. We provide support that ensures the best outcomes for all our customers.

Phone

1800 82 42 42 

Operating Hours

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

Address

12 Blackman Avenue, Mill Park VIC 3082

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

Referrer Name(Required)
Name(Required)
Preferred method of contact
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