Participant Exit or Transition Form

Step 1 of 2

Participant Exit or Transition Form

Participant Name:*

Services Cease Date*

NDIS Number:*

Commencement of Service:*

Service Completed Permanent transfer Temporary transfer Exit

Date of Birth*

Notes/Comments:

Reason for End of Service*

Reason for temporary transfer*

What are the client's exit or transition goals?*

Referrals and linkages to other services and activities will best meet the client's needs*

Other comments:

Step 2 of 2

(Mark of individual items below as completed and comment)

Family Doctor / GP

Allied Health Providers

Other clubs and services

Name and Contact Number

Checkboxes*

All relevant staff - notified by phone as well as a memo in file for all staff to note. Administration and Management. Loan equipment retrieved from the client's home. (If applicable). Client home chart collected for filing. Client office file put in order and archived with the date of disposal on front of the file (7 years from the date of the end of service) Contacted the participant and the participant has agreed to and consented to electronic signature and receipt of this form.

Participant or Representative Name*

Participant or Representative Signature*

Staff - CARE ZONE

Date*

Your responses are submitted securely and stored in Care Zone's confidential records.