Holistic Healthcare
0480 732 743

FORM-67-Participant Exit Form

Participant Exit Form

Record of participant exit details, services provided, property return, feedback, and transition next steps.

Participant Details

Full Name:  
Date of Birth:  
NDIS Number:  

Exit Details

Date of Exit:  
Reason for Exit:
  • ☐ Participant request
  • ☐ Change in service needs
  • ☐ Transfer to another provider
  • ☐ Relocation
  • ☐ No longer requires services
  • ☐ Other: ____________________________________________
Was the participant satisfied with the services received? ☐ Yes     ☐ No
If “No”, please explain:  
Final Meeting Date (if applicable):  
Participant’s Transition or Exit Goals  

Services Provided

Service Type Start Date End Date Comments
       
       
       
       

Property and Equipment Return

Item Returned Condition Comments
e.g., Communication Devices Yes/No Good/Fair/Poor Details of condition of returned items
       
       
       
       

Participant Feedback

Question Yes No N/A Comments
Were you satisfied with the quality of services received?        
Did the services meet your needs and goals?        
Were the staff respectful and professional?        
Was the communication with the service provider effective?        
Would you recommend our services to others?        

Do you have any suggestions for improving our service delivery?
 

Follow-Up and Next Steps

Action Required Responsible Person Due Date Comments
e.g., Transfer records to new provider Staff Name DD/MM/YYYY Any relevant comment
       
       
       

Signatures

Participant/Guardian
Name:  
Signature:  
Date:  
Service Provider Representative
Name:  
Signature:  
Date:  
Support Coordinator (if applicable)
Name:  
Signature:  
Date:  

Thank You

Thank you for allowing us to support you during this time. We wish you all the best in your future endeavours.