Participant Intake Form

Welcome to Moonlit Supports! We’re here to provide safe, reliable, and person-centred support tailored to your needs. Once you submit this intake form, a member of our team will be in touch shortly to guide you through the next steps and explore the support options available.

We can’t wait to get to know you and start supporting your journey!

Participant Details:

Participant Name

First Name

Last Name

Date of Birth

Day

Month

Year

Address

Phone

Email

Primary Contact:

Primary Contact First Name

Primary Contact Last Name

Relationship to Participant

Phone

Email

Preferred Contact Method:

Phone

Email

SMS

What type of Services does the participant require?

Assistance with Meal Planning and Preparation

Support with Community Access

Assistance with Daily Tasks / Personal Activities

Assistance with Household tasks, Maintenance or Cleaning

Support with Travel and Transport

How often do you expect to use this type of support?

Rarely – I would use this support only in unusual or infrequent situations.

Sometimes – I would use this support off and on, but not on a regular schedule.

Often – I would access this support regularly, though not every day.

Very Often – I would rely on this support most of the time.

Always – I would need this support daily or continuously.

How long do you expect to need this support?

Short-term (a few days to a few weeks)

Medium-term (a few months)

Long-term (ongoing or indefinite support)

Other

Are you ready to get started with us now, or is this more of a later thing?

Anything else you want us to know?

Do you require High Intensity Supports?

No

Yes

NDIS Number

Plan Details

Self-Managed

Plan-Managed

NDIA-Managed

Plan Manager (if applicable)

Plan Manager Contact Details

Do you require assistance with any of the following areas? Please tick all that apply.

Agreement of Terms & Conditions

I consent for collection, use, and storage of my personal information

I agree to the NDIS Terms of Use - https://www.ndis.gov.au/policies/terms-use

Marketing Consent

I consent to have my photo and video taken for marketing purposes

I do NOT consent to have my photo and video taken for marketing purposes