Do you have any pets?*
Please answer the question.
Please answer the question.
If yes, details of Pets
Please enter details.
Please enter details.
Do you have a swimming pool?*
Please answer the question.
Please answer the question.
Is this is a smoke free home?*
Please answer the question.
Please answer the question.
Are there any environmental hazards in the home we should be aware of? (e.g. renovations, multi-story etc.)*
Please answer the question.
Please answer the question.
If yes, details of Environmental Hazards
Please enter details.
Please enter details.
Will the family accept responsibility for taking all responsible care to protect the staff member form all forms of abuse by family members and guests?*
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Please answer the question.
Are there any custody orders in place for children?*
Please answer the question.
Please answer the question.
If yes, details of Custody Orders
Limit of 200 characters
Please enter details and limit your answer to 200 characters (including spaces).
Please enter details and limit your answer to 200 characters (including spaces).
Are there other people living in the home other than the participant and their family?*
Please answer the question.
Please answer the question.
If yes, details of Other People Living in the Home
Please enter details.
Please enter details.
Is anyone at the property known to be aggressive or violent?*
Please answer the question.
Please answer the question.
If yes, details
Please enter details.
Please enter details.
Does anyone at the property have a criminal history?*
Please answer the question.
Please answer the question.
If yes, details
Please enter details.
Please enter details.
Are you aware of any occupant having an infectious disease?*
Please answer the question.
Please answer the question.
If yes, details
Please enter details.
Please enter details.
Is there a history of drugs or alcohol misuse at the property?*
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Please answer the question.
If yes, details
Please enter details.
Please enter details.
Are you aware of any firearms stored at the property?*
Please answer the question.
Please answer the question.
If yes, details
Please enter details.
Please enter details.
Are there any other factors we should be aware of?*
Please answer the question.
Please answer the question.
If yes, details
Please enter details.
Please enter details.
Please list risk management actions do you currently have in place. What additional risk management actions do you suggest?
Limit of 200 characters
Please enter details and limit your answer to 200 characters (including spaces).
Please enter details and limit your answer to 200 characters (including spaces).
Full Name*
Please enter your emergency contact's full name.
Please enter your emergency contact's full name.
Mobile Phone Number*
Please enter your emergency contact's phone number.
Please enter your emergency contact's phone number.
Relationship to participant*
Please enter your emergency contact's relationship to you.
Please enter your emergency contact's relationship to you.
Specific Instructions*
Limit of 200 characters
Please enter specific instructions and limit your answer to 200 characters (including spaces).
Please enter specific instructions and limit your answer to 200 characters (including spaces).
Full Name*
Please enter your emergency contact's full name.
Please enter your emergency contact's full name.
Mobile Phone Number*
Please enter your emergency contact's phone number.
Please enter your emergency contact's phone number.
Relationship to participant*
Please enter your emergency contact's relationship to you.
Please enter your emergency contact's relationship to you.
Specific Instructions*
Limit of 200 characters
Please enter specific instructions and limit your answer to 200 characters (including spaces).
Please enter specific instructions and limit your answer to 200 characters (including spaces).
If you have any other supports, please fill in their contact details
For example: advocate, plan manager, local area coordinator, support coordinator, occupational therapist, physiotherapist, psychologist, or other service provider
Contact Type
- - select an option -
Doctor
Advocate
Plan Manager
Local Area Coordinator
Support Coordinator
Occupational Therapist
Physiotherapist
Psychologist
Other Service Provider
Field is required!
Field is required!
Contact Full Name
Please enter the contact's full name.
Please enter the contact's full name.
Contact's Company Name
Please enter the contact's company name.
Please enter the contact's company name.
Contact Mobile Phone Number
Please enter the contact's mobile phone number.
Please enter the contact's mobile phone number.
Contact Landline Phone Number
Please include the area code
Please enter the contact's landline phone number.
Please enter the contact's landline phone number.
Contact Email
Please enter the contact's email.
Please enter the contact's email.
Contact Postal Address
Please enter the contact's postal address.
Please enter the contact's postal address.
Please indicate the type of information to share with this contact
Field is required!
Field is required!
Contact Type
- - select an option -
Doctor
Advocate
Plan Manager
Local Area Coordinator
Support Coordinator
Occupational Therapist
Physiotherapist
Psychologist
Other Service Provider
Field is required!
Field is required!
Contact Full Name
Please enter the contact's full name.
Please enter the contact's full name.
Contact's Company Name
Please enter the contact's company name.
Please enter the contact's company name.
Contact Mobile Phone Number
Please enter the contact's mobile phone number.
Please enter the contact's mobile phone number.
Contact Landline Phone Number
Please include the area code
Please enter the contact's landline phone number.
Please enter the contact's landline phone number.
Contact Email
Please enter the contact's email.
Please enter the contact's email.
Contact Postal Address
Please enter the contact's postal address.
Please enter the contact's postal address.
Please indicate the type of information to share with this contact
Field is required!
Field is required!
Contact Type
- - select an option -
Doctor
Advocate
Plan Manager
Local Area Coordinator
Support Coordinator
Occupational Therapist
Physiotherapist
Psychologist
Other Service Provider
Field is required!
Field is required!
Contact Full Name
Please enter the contact's full name.
Please enter the contact's full name.
Contact's Company Name
Please enter the contact's company name.
Please enter the contact's company name.
Contact Mobile Phone Number
Please enter the contact's mobile phone number.
Please enter the contact's mobile phone number.
Contact Landline Phone Number
Please include the area code
Please enter the contact's landline phone number.
Please enter the contact's landline phone number.
Contact Email
Please enter the contact's email.
Please enter the contact's email.
Contact Postal Address
Please enter the contact's postal address.
Please enter the contact's postal address.
Please indicate the type of information to share with this contact
Field is required!
Field is required!
Please enter details about the involvement of the participant, family, advocate, other contacts about the decision-making process*
Limit of 200 characters
Please enter details and limit your answer to 200 characters (including spaces).
Please enter details and limit your answer to 200 characters (including spaces).
I would like to opt out of the audit process
All registered NDIS Service Providers need to be audited every 18 months - 3 years. Auditors like to interview participants. Please let us know if you would like to opt out of being contacted by our auditors.
Field is required!
Field is required!
I confirm that all information completed within my Registration form is true and accurate. In order for ALHCA to commence providing service, I also agree to allow ALHCA to share my information with family, guardians, advocates, support workers, support coordinators, local area coordinators, plan managers, relevant health care professionals, other providers, government bodies, welfare supports, referral organisations and other authorised personnel where necessary. We've recorded the level of sharing with your contacts as preciously indicated. You can withdraw this consent at any time however the Agency is required by law in some circumstances to disclose information.*
Public, online or promotional use of your private information will require ALHCA to have you sign a further consent form.
Please confirm.
Please confirm.
