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PARTICIPANT INTAKE FORM

URGENCY LEVEL
Immediate / Requires urgent attention within the next 24 hours due to severe health or safety risks.
High Priority / Needs to be addressed within 1-3 days to prevent escalation of risks or issues.
Moderate Priority / Should be handled within a week; there is a need, but it’s not currently critical.
Routine / No immediate risks; can be scheduled within the next 2 – 4 weeks.
Non-Urgent / Flexible timing; can be addressed as resources allow.

PARTICIPANT DETAILS

Participants Address

Preferred Date & Time for Property Inspection
Day
Month
Year
Time
HoursMinutes
Available Parking

Primary Disability

Secondary Disability and Other Health Conditions

Support Coordinator / Plan Manager / Source of Funding

NDIS Plan Category

Authorisation

Do you permit Residence Revival to make direct contact with the Participant's Plan Manager to examine and assist with approval of funding.
Yes
No

For Residence Revival to provide a successful outcome for the Participant, we endeavor to be proactive in communicating and assisting with Plan Managers and the NDIS, specifically ensuring adequate funding is available within the plan for Deep Cleaning, Hoarding or Squalor Restoration.


-If possible, please provide a copy of the participants NDIS plan and O.T. Report.

- Please Note: During the initial meeting and property inspection, we will request a signed authority from the participant to contact their Plan Manager.

Participant's Information

Service Request
Risk/Hazards
Cleaning with Dignity, Empathy, Care

Residence Revival - Dignity, Empathy, and Care in Every Step Restoring lives, one home at a time.

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02 4879 9189

admin@residencerevival.com.au

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We respect and honour Aboriginal and Torres Strait Islander Elders past, present, and future. We acknowledge the stories, traditions, and living cultures of Aboriginal and Torres Strait Islander peoples on this land and commit to building a brighter future together.

© 2025 Residence Revival

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