Client Intake Form – Stream Services

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Register
Login

Home
Our Services
How it Works
Our Story
Pricing
Make a Referral
Careers
Blog
Contact

Client Intake Form

Thank you for registering with Stream Services. If you’re a current member please sign in, otherwise fill in the form below.

We take your privacy and data security seriously! Find out how.

Need Help? Call us now: 1300 721 964

- Upload for dev purposes, dont' delete
- Thank you for registering with Stream Services. If you’re a current member please sign in, otherwise fill in the form below.
- I am completing this on behalf of an NDIS Participant*
  - Yes
  - No
- Personal Details of NDIS Participant
- My first name is*
- My last name is*
- My phone number is* Required phone number format: ##########
- My e-mail address is:*
- My date of birth is*
- Select your region*
  - Non-remote
  - Remote
  - Very remote
  - I don't know and I would like to speak to about this after I complete this form
  (Check Map) Remote is a location zoned Modified Monash Model 2015 Zone 6 or communities surrounded by MMM6 area, Very Remote is MMM7 areas. See NDIS Price Guide for more information about NDIS zoning
- - My address is:
  - Address*
  - Town / City*
  - State / County*
  - Postcode*
- My gender is*
- The main language I speak at home is:
- Do I require an interpreter (Oral, Auslan, Tactile Interpreter)?*
- My Living arrangements are
- The names and relationships to me of the people who live with me are Eg: Sarah (sister), Steph (friend from school)
- Do I have any guardianship or custody orders in place?*
  - Yes
  - No
- Trusted Person
  Please enter the details of your trusted person or emergency contact
- The name of my trusted person is:*
- This person is my (Example: friend, partner)*
- This person's email is
- This persons phone number is* Required phone number format: ##########
- My NDIS Information
- Do you have an NDIS plan?*
  - Yes
  - No
- My Medicare card expiry date
- NDIS plan start date
- NDIS plan end date
- What is my primary impairment / disability? (Note for multiple impairments/disabilities) If you have multiple disabilities please note the others below. The Primary impairment is an NDIS term which is the impairment or disability which impacts upon your day to day life the most
- Do I have a history of challenging behaviours or risks related to self harm or harm to others?*
  - Yes
  - No
- Please answer where applicable: I have a history of the following mental health or health diagnosis conditions other than any impairment mentioned above.
- I have the following allergies
- I have the following phobias (if any) you should be aware of
- Do you want to write or upload your goals?*
  - Write
  - Upload
- My NDIS Plan
- What services am I interest in from Stream Services?*
  - Occupational Therapy
  - Psychology
  - Exercise Physiology
  - Dietetics
  - Coordination of Supports
  - Lifestyle Support Worker
  Don't worry if you are not sure your answer is correct, you can change this any time in the future, your coordinator or one of our helpful staff can assist you if you are unsure.
- number dev select
  - yes
  - no
  test
- My NDIS Plan (continued)
- I have read and understand the Service Terms and Conditions.*
- Agreement
- Username*
- Is there any other information you think we should know
- How would you like us to contact you?*
  - Text/SMS
  - Email
  - Both
- Nominate frequency of notifications
- Would you like to add another email address to receive all of your Stream Services correspondence?
- Create a password:* To create your password, type it into the box above. If you forget your password or have trouble accessing your account, you can always contact us for help.
- Please note, all information is stored on Australian servers, in accordance with Australian Privacy Principles

<img width="300" height="280" src="https://streamservices.com.au/wp-content/uploads/2022/02/SS_Stacked_1-1.png" class="image wp-image-19304 attachment-medium size-medium" alt="" decoding="async" style="max-width: 100%; height: auto;" srcset="https://streamservices.com.au/wp-content/uploads/2022/02/SS_Stacked_1-1.png 1695w, https://streamservices.com.au/wp-content/uploads/2022/02/SS_Stacked_1-1-600x560.png 600w" sizes="(max-width: 300px) 100vw, 300px" />

SPECIALISTS IN DELIVERING NDIS SERVICES TO ALL AUSTRALIANS

Stream Services is the brainchild of registered NDIS Provider Clermont Country Care. Founded in remote Queensland to deliver exceptional services for people living in country communities or who are otherwise isolated.

<img decoding="async" alt="I love NDIS" class="i-love-ndis-footer" src="https://streamservices.com.au/wp-content/uploads/2020/04/I-Heart-NDIS_2020.png" />

Stream Services acknowledges the Traditional Owners of Country throughout Australia.

© 2023 Stream Services. Proudly built by Clearshot Digital Privacy Policy Feedback

<img width="300" height="280" src="https://streamservices.com.au/wp-content/uploads/2022/02/SS_Stacked_1-1.png" class="image wp-image-19304 attachment-medium size-medium" alt="" decoding="async" style="max-width: 100%; height: auto;" srcset="https://streamservices.com.au/wp-content/uploads/2022/02/SS_Stacked_1-1.png 1695w, https://streamservices.com.au/wp-content/uploads/2022/02/SS_Stacked_1-1-600x560.png 600w" sizes="(max-width: 300px) 100vw, 300px" />

SPECIALISTS IN DELIVERING NDIS SERVICES TO ALL AUSTRALIANS

Stream Services is the brainchild of registered NDIS Provider Clermont Country Care. Founded in remote Queensland to deliver exceptional services for people living in country communities or who are otherwise isolated.

<img decoding="async" alt="I love NDIS" class="i-love-ndis-footer" src="https://streamservices.com.au/wp-content/uploads/2020/04/I-Heart-NDIS_2020.png" />

Stream Services acknowledges the Traditional Owners of Country throughout Australia.

© 2023 Stream Services. Proudly built by Clearshot Digital Privacy Policy Feedback