Participant Intake · PurpleCare

Personal details

Tell us who you are.

Full legal name *

Preferred name (optional)

Date of birth *

Gender *

Street address *

Suburb *

State *

Postcode *

Mobile phone *

Home phone (optional)

Email *

Disability & health

Help us understand your condition and support needs.

Primary disability / condition *

Date of onset / injury (optional)

Formal diagnosis (if any)

Other medical conditions

Pressure sores

Yes No

Current injuries

Yes No

Physical limitations

Cognitive limitations

Communication needs

NDIS & funding

Your plan details, if applicable.

Are you an NDIS participant? *

Yes No

Are you in a SIL plan?

Yes No

Support network

People who help coordinate your care.

Support coordinator (optional)

Name

Organisation

Phone

Email

Plan manager (optional)

Name

Organisation

Phone

Email

Emergency contact *

Name *

Relationship *

Phone *

Medications

List all current medications. Add a row for each.

Your goals

What does good support unlock for you?

Short-term goals

Long-term goals

Personal goals

Anything else?

Add anything that helps us provide the right support.

General notes

I consent to PurpleCare collecting and storing my personal information in accordance with the Privacy Policy. I understand my data is stored in Australia (Supabase ap-southeast-1), retained per NDIS requirements (7 years), and that I may request access, correction or deletion at any time by contacting support@purplecare.com.au.

Signature *

By signing below I confirm the information I have provided is true and complete to the best of my knowledge, and I agree to the PurpleCare service agreement and privacy terms.

Sign with your finger, stylus, or mouse.

Tell us about your needs.