Client Onboarding Form

Client Details:

First Name *

Last Name *

Date of Birth *

Phone Number

Email Address

Street Address *

City *

State *

Postcode *

Gender

MaleFemaleintersex

Client NDIS Number:

Client NDIS Plan Date:

Client Representative Details (If Applicable)

Provide Plan Manager (if applicable) see NDIS Funding Type

First Name

Last Name

Phone Number

Email

Referrer's Address:

Referrer’s name (If Applicable):

Referrer’s relationship with client:

Plan Manager Agency (If Applicable)

Support preferences for the Client:

Is the client enrolled in school?

Full days (5 Days)Partial daysDoes not attend school

On which days does the client attend school, and what are their start and finish times?

Is the client employed?

YesNo

On which days does the Client attend work, and if so, what are their days and start and finish times?

Preferred Times for Mentoring (e.g., Morning, Daytime, Afternoon - After School/work) *

Morning (between 8:00 am to 1:00 pm)Afternoon (between 1:00 pm to 7:00 pm)Both (Flexible)

How often would you like to meet with your mentor?

Mentorship Goals & Interests:

Why do you want to join this mentorship program?

What do you hope to gain from having a mentor?

What are your NDIS Goals?

What are some hobbies or activities you enjoy?

Are you interested in (check all that apply):

Personal Development & Well-being:

Do you feel confident in setting and achieving goals?

YesNoUnsure

Do you have a trusted person you can talk to when you face challenges?

YesNoUnsure

What is one personal goal you would like to achieve with a mentor’s help?

Do you have any challenges or barriers that affect your personal growth? (Optional)

Is there anything else we should know to better support you?

Mentor Preferences:

Do you prefer a mentor who has experience in a specific career or field? (Yes/No)

Would you like a mentor of a specific gender? (Yes/No)

Additional information:

By signing below, you confirm your consent and agreement to the information provided in this client intake form

Is there anything else you would like us to know to better support the Client?

Required Documents to be Uploaded

NDIS GoalsBehaviour Support Plan

File Upload (Please attach a copy of the current required documents)

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Full Name:

Date:

Signature *

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Signed for and on behalf

of Young Leaders Youth Services
ABN 595 533 941 53 PTY LTD (Young Leaders Youth Services), by: