Your Full Name
*
Your Email Address
*
Your Mobile Number
*
Your Relationship to Participant
*
I am the Participant
Support Coordinator
Key Worker
NDIS Contact
Parent/Carer
Other
Participant First Name
*
Participant Last Name
*
Participant Date of Birth
*
Is the participant a child, or have someone to support their communication with us like a representative?
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Yes
No
Representative/Parent Name
*
Parent/Representative Email
*
Parent/Representative Mobile
*
Participant Email
*
Participant Mobile
*
Gender
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Male
Female
Non-Binary
Other
Prefer not to say
Preferred Pronouns
*
Home Address
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Are we supporting with school pick up?
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Yes
No
School Address & Name
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Provide as much detail as you can, pick up location (office, car park, across the road), school finish time ect
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Funding Management Type
Self Managed
Plan Managed
Private Paying
Participant NDIS Number
*
Participant NDIS Plan Dates
*
Invoice Email
*
Plan Manager Email
*
Support Coordinator Name, Email & Mobile (if you have one)
Emergency Contact Name, Relationship, & Mobile
*
Line Item/Funding Category Requested
*
Days & Times of Support or Service
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Allergies
Does the participant have a Behaviour Support Plan?
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Yes
No
In Progress
Please upload a copy of the BSP
*
Browse
Does the participant have a seizure management plan?
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Yes
No
Please upload a copy of the seizure management plan
*
Browse
Does the participant have an Asthma management plan?
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Yes
No
Please upload a copy of the Asthma management plan
*
Browse
Does the participant have an Anaphylaxis management plan?
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Yes
No
Please upload a copy of the Anaphylaxis management plan
*
Browse
What goals would you like to work on or work towards during support?
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What should support look like/what would you like to take place during support?
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How does the the participant typically communicate needs when upset, overwhelmed or frustrated?
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How do you typically communicate your needs when upset or overwhelmed?
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Does the participant have any specific triggers? Sensory, demand avoidance, care-seeking behaviours.
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Do you have any specific triggers? Sensory, demand avoidance, overwhelm, anxiety ect
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Are there any games, toys, activities, interests or hobbies that can be incorporated?
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Are there any games, activities, interests or hobbies that can be incorporated?
*
How does the participant handle transitions? E.G School to activity, iPad to dinner time, work to home
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How do you typically handle transitions from one task to another?
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Are there any specific cues or triggers that can make transitions easier?
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Are there any challenging behaviours we should know about?
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Can include hitting, kicking, biting, screaming/yelling, crying, running away
Are there any safety concerns or medical considerations we should know about?
Does the participant require physical assistance?
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With walking, showering/self care, moving from ground to car ect
Do you require any physical assistance?
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With walking, showering/self care, moving from ground to car ect
Preferred method of communication of the participant?
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Email
Call
Text
What is your preferred method of communication?
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Email
Call
Text
Do you have any particular communication needs?
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Simple English, Key Word Sign, PDA Friendly Language, AAC Devices
Does the participant have any particular communication needs?
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Simple English, Key Word Sign, PDA Friendly Language, AAC Devices
If the participant is a child - how do they typically behave with a support worker during sessions or activities?
If the participant is a child, what is their sense of road safety like and are they safe to travel in a vehicle?
*
If the participant is a child, is a car seat required?
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No
Booster Seat
5 Point Harness
Other
Will medication need to be administered during supports?
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Yes
No
Unsure
In the event of a natural disaster, does the participant require our assistance? (Outside of shift times)
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Yes
No
For example: Supports are on Mondays only and there is a bushfire on Tuesday. Is support from us required?
Does the participant/household have an emergency management plan/evacuation plan/fire evacuation plan?
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Yes
No
Unsure
What type of premises is the home address?
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House
Unit
Townhouse
Caravan Park
SRS
Is the street sign or property number easy to see?
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Yes
No
Is parking available on the road or in the driveway?
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Road
Driveway
Carpark
No Parking
Other
If there is a gate, is it difficult to open?
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Yes
No
No Gate
Are there any dangerous/uneven paths leading to the house?
Yes
No
Not Applicable
Are there any dangerous/slippery steps?
Yes
No
No Steps
Are there any animals with open access to the front yard of the property, or will be unrestrained inside the house?
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Yes
No
All Animals & pets must be restrained to allow safe access to & from the property
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I agree
I disagree
Other - would like to chat
Is it likely that any people in the home will be smoking or drinking alcohol during our visit?
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Yes
No
Does anybody smoke inside the house?
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Yes
No
No - outside
Is the participant or anyone in the house undergoing Cytotoxic treatment? (E.G Chemotherapy)
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Yes
No
Other - would like to chat
Is there any known substance use amongst people who may be present?
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Yes
No
Are there any known weapons/guns in the house?
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Yes
No
Please Describe
*
Anything else we should know?
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