Residential Cleaning Client Intake Form | A Place of Calm

A Professional Organising and Decluttering Service in Geelong, Victoria

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Residential Cleaning Client Intake Form

Date of Referral:

Client's Details

Name:

Date of Birth:

Pronouns:
She/HerHe/HimThey/ThemPrefer not to say

Address:

Preferred Contact:

Name of NOK/Emergency Contact:

Relationship:

Contact Phone:

Indigenous/Cultural Identity:

Referrer Details

Name:

Organisation:

Position:

Address:

Email:

Phone:

Is funding received through any of the following?

NDISHome Care PackageDVA (Dept of Veteran Affairs)DFFS (Dept of Family, Fairness and Housing)Other

If NDIS Participant:

Plan ManagedSelf-Managed

NDIS No.:

Plan Manager (include email for invoices):

Areas of concern:

KitchenBathroom/sToilet/sVacuuming and mopping floorsDustingLaundryOther

Frequency of cleaning:

WeeklyFornightlyMonthlyOther

Preferred Day:

MondayTuesdayWednesdayThursdayFriday

Preferred Time:

MorningAfternoon

Additional Notes:

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