Client Details

Minimum data set — demographic information, referral pathway and presenting issues

How to use: Fill in the fields below. Data is saved automatically to this browser session. Use the bar at the bottom to copy a JSON record or clear the form.

Demographic information

Core client details based on the draft minimum data set.

Client name

Client email

Client address

Date of birth

Gender

Specify different term

Postcode

Nature of accommodation

Household composition

Dependants (specify ages)

Country of birth

Main language spoken at home

Aboriginal or Torres Strait Islander origin

Highest level of education

Employment status

Source of income

Does the client have a disability?

Neurodevelopmental Disorders Physical Disability Acquired Brain Injury (ABI) Neurological Disability Vision Impairment Hearing Impairment Deafblind (Dual sensory) Speech Language Impairment Psychosocial Disability Developmental Delay

Referral in

Select the pathway — the form retains both the category and the specific source.

Referral in pathway

Please specify

Presenting issues

Multi-select. Each issue is grouped under a category.

Other presenting issue — please specify

Referral out

Multi-select any service, creditor or pathway the client is referred to.

Other referral out — please specify

Data is saved in this browser session.