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CuraOne Group Pty Ltd - Client Intake Form

CARE • SUPPORT • COMMUNITY

Please complete this quick form to establish your support profile. Services are delivered under our non-clinical managed welfare framework.

Client Profile

Prefix *

Client First Name *

Middle Name

Last Name *

Date of Birth *

Gender

Preferred Language *

Residential Address

Unit / Apartment Number

Street Number & Street Name *

Suburb / Town *

Postcode *

State *

Is Postal Address same as Residential? *

Contact & Funding

Mobile Phone *

Email Address *

Main Contact Person Name *

Relationship to Client *

Main Contact Phone *

Main Contact Email

Funding Type *

Referral Source

Compliance Agreement & Declaration

Primary Support Needs Requested *

Medical Notes / Material Allergies

Cultural or Religious Considerations

Communication Needs

Access, Pets or Home Safety Notes

Compliance Agreement & Declaration *

* I accept the CuraOne Service Terms: (2-Hour Minimum per shift; 48-Hour Cancellation policy; and face-to-face community transport billed at $2.00 per kilometer).

* I confirm that all provided details are true and correct, and I acknowledge that CuraOne Group Pty Ltd delivers strictly non-clinical managed welfare, home, and yard services.

Sign-off & Execution

Client / Representative Full Name *

Electronic Signature Block *

Sign here

Execution Date *

By submitting this form, I confirm that I have read, understood and agree to the acknowledgements above. I understand that completing this form does not guarantee service availability or funding approval.