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It guides service providers on distributing or adapting the form, including tailoring questions to required demographic data. The document includes consent and privacy sections covering confidentiality, use of an IT system called “Data Exchange,” and compliance considerations under the Privacy Act 1988, plus guidance on adding organization-specific privacy and terms information.",{"@graph":63,"@context":119},[64,80,102],{"@type":65,"itemListElement":66},"BreadcrumbList",[67,71,74,77],{"item":68,"name":69,"@type":70,"position":9},"https://docshare.wps.com","Home","ListItem",{"item":72,"name":10,"@type":70,"position":73},"https://docshare.wps.com/template/",2,{"item":75,"name":36,"@type":70,"position":76},"https://docshare.wps.com/template/forms/",3,{"item":78,"name":59,"@type":70,"position":79},"https://docshare.wps.com/template/example-client-intake-form-september-2024/306970/",4,{"url":78,"name":59,"@type":81,"image":82,"author":87,"headline":59,"publisher":90,"fileFormat":93,"inLanguage":57,"description":61,"dateModified":94,"datePublished":95,"encodingFormat":93,"isAccessibleForFree":96,"interactionStatistic":97},"DigitalDocument",{"url":83,"@type":84,"width":85,"height":86},"https://docshare.wps.com/thumbnails/example-client-intake-form-september-2024/306970.png","ImageObject",442,249,{"name":88,"@type":89},"Angel","Person",{"url":68,"name":91,"@type":92},"DocShare","Organization","application/pdf","2026-10-23","2026-09-19",true,{"@type":98,"interactionType":99,"userInteractionCount":101},"InteractionCounter",{"@type":100},"ViewAction",7,{"@type":103,"mainEntity":104},"FAQPage",[105,111,115],{"name":106,"@type":107,"acceptedAnswer":108},"What demographic information does the intake form collect?","Question",{"text":109,"@type":110},"The form collects details such as full/preferred name, date of birth, gender, address, country of birth, main home language, Aboriginal or Torres Strait Islander identity, impairments/conditions, homelessness risk, household makeup, referral source, and main reasons for seeking help.","Answer",{"name":112,"@type":107,"acceptedAnswer":113},"Should service providers always use this intake form?",{"text":114,"@type":110},"Service providers can distribute the form to clients to collect needed demographic information, but they are not required to use it. They may choose another approach that is more appropriate and consider whether asking clients to complete the form is suitable and comfortable for them.",{"name":116,"@type":107,"acceptedAnswer":117},"How does consent and privacy work for the data collected?",{"text":118,"@type":110},"Service providers must seek consent for their own use of the data, separate from consent for using the Data Exchange. The template instructs providers to include a statement aligned with their organization’s privacy policy and to consider compliance with the Privacy Act 1988 and any additional client terms and conditions.","https://schema.org",{"og:url":78,"og:type":121,"og:title":59,"og:site_name":91,"og:description":61},"article",{"robots":123,"canonical":78},"index,follow",{"doc_id":125,"site_id":56},306970,1790814596,{"code":4,"msg":5,"data":128},{"doc_id":125,"user_id":129,"nickname":88,"user_avatar":130,"doc_module":9,"category_id":35,"category_name":36,"doc_title":59,"doc_description":61,"doc_content":131,"file_id":132,"file_url":133,"file_type":134,"file_size":135,"view_count":101,"is_deleted":4,"is_public":9,"is_downloadable":9,"audit_status":9,"page_count":101,"language":136,"language_code":57,"site_id":56,"html_lang":57,"table_of_contents":137,"faqs":138,"seo_title":139,"seo_description":61,"update_tm":140,"read_time":76},687207412472,"https://ap-avatar.wpscdn.com/davatar_155a257f0dc6eb9ab79c44ca47cae57d","*** DELETE THIS PAGE BEFORE DISTRIBUTING TO CLIENTS ***  \nExample client intake form  \nSeptember 2024  \nNote for service providers  \n• You can distribute this form to your clients to collect the demographic information you need to report in the Data Exchange.  \n• You do NOT need to use this form. You may choose to use your own intake form or collect information in a way that is more appropriate for your clients.  \n• It may not be appropriate to ask a client to complete this form. Additionally, some clients may not feel comfortable completing this form. Use your professional judgement to determine to best way to collect this information.  \n• If you do use this form, you should tailor it to your service and clients.  \no Consider the demographic information your service needs and add relevant questions to the form. For example, whether your clients are working or studying, how many children they have, how long they have lived in Australia etc.  \no You may not need to record this information in the Data Exchange, but it will be useful for planning your services.  \nImportant – Consent and privacy  \n• Service providers need to seek consent for their own use of this data. This consent is separate to the consent sought for using the Data Exchange.  \n• If you use this document, you should include a statement that is specific to your organisation’s privacy policy in the ‘consent’ section.  \n• You must also consider how your organisation will collect and use personal information, and what consent arrangements may be required to ensure you are compliant with the Privacy Act 1988.  \n• Your service might have its own terms and conditions that clients need to agree to. You should also add this information to the document, if you use it.  \n*** DELETE THIS PAGE BEFORE DISTRIBUTING TO CLIENTS ***  \nDate: _  \n_  \n\u003CInsert name of service>: Intake form  \nBelow are some demographic questions. This information will help us better understand you and your needs and how we can best help you address them.  \nAll the information you provide will be strictly confidential.  \n1. What is your full name or preferred name / pseudonym?  \n2. What is your date of birth or estimated date of birth?  \n3. What is your gender?  \n\n| ☐ | Man or male |\n| --- | --- |\n| ☐ | Woman or female |\n| ☐ | Non-binary |\n| ☐ | [I/They] use a different term |\n| ☐ | Not stated |\n\n4. What is your address? If you do not want to disclose your full address, please provide us with just your suburb, state and postcode.  \n\n| Address line 1: |  |\n| --- | --- |\n| Address line 2: |  |\n| Suburb: |  |\n| State: |  |\n| Postcode: |  |\n\n5. What country were you born in?  \n6. What is the main language you speak at home? If you speak more than one language at home, please write the language that is spoken most often.  \n7. Do you identify as Aboriginal or Torres Strait Islander?  \n\n| ☐ | No |\n| --- | --- |\n| ☐ | Aboriginal |\n| ☐ | Torres Strait Islander |\n| ☐ | Aboriginal and Torres Strait Islander |\n\n8. Do you have any of the following impairments, conditions or disabilities?  \nPlease select all that apply. Medical documentation is not required. For information about each category speak to your practitioner or service provider.  \n\n| ☐ | Intellectual learning |\n| --- | --- |\n| ☐ | Psychiatric |\n| ☐ | Sensory/speech |\n| ☐ | Physical/diverse |\n| ☐ | None |\n\n9. Are you homeless or at risk of being homeless?  \n\n| ☐ | Yes |\n| --- | --- |\n| ☐ | No |\n| ☐ | At risk |\n\n10. How would you describe the makeup of your household?  \n\n| ☐ | Single (person living alone) |\n| --- | --- |\n| ☐ | Sole parent with dependent(s) |\n| ☐ | Couple |\n| ☐ | Couple with dependent(s) |\n| ☐ | Group of related adults |\n| ☐ | Group of unrelated adults |\n| ☐ | Homeless/no household |\n\n11. Where you referred to us by another organisation, service or program? If so, please provide the name below. If you were referred to us by a friend or family member please state this below.  \n12. From the list below, please choose the main reason you are see","cbCaiaGmekUG2y6k","https://ap.wps.com/l/cbCaiaGmekUG2y6k","pdf",226141,"English","# Intake form\n## Demographic questions\n## Consent and privacy","[{\"question\":\"What demographic information does the intake form collect?\",\"answer\":\"The form collects details such as full/preferred name, date of birth, gender, address, country of birth, main home language, Aboriginal or Torres Strait Islander identity, impairments/conditions, homelessness risk, household makeup, referral source, and main reasons for seeking help.\"},{\"question\":\"Should service providers always use this intake form?\",\"answer\":\"Service providers can distribute the form to clients to collect needed demographic information, but they are not required to use it. They may choose another approach that is more appropriate and consider whether asking clients to complete the form is suitable and comfortable for them.\"},{\"question\":\"How does consent and privacy work for the data collected?\",\"answer\":\"Service providers must seek consent for their own use of the data, separate from consent for using the Data Exchange. The template instructs providers to include a statement aligned with their organization’s privacy policy and to consider compliance with the Privacy Act 1988 and any additional client terms and conditions.\"}]","Example client intake form - September 2024 | PDF",1789842752]