CARE AUSTRALIA

Participant Details

Disability Support and Service

Third

Forth

2.Participant NDIS No.

NDIS Plan Start date

NDIS Plan End Date

How is your funding managed? Self Managed

If Self-Managed, Please provide Invoicing information

If Plan Managed, Please provide Invoicing information

If NDIA Managed,A document for digital signature giving us an authority to get their NDIS plan from NDIS

File Upload

Do you have a Support Coordinator?

Yes

If Yes

Do you have a Local Area Coordinator?

Yes

If Yes

What is the participant support ratio?

3.Participant DOB

26 years 256 Days Old

4.What does participant identify as?

5.Participant current Living Arrangement

6.Participant Phone No.

7.Do you have a Plan Nominee / Guardian?

Yes

If Yes

8.Form Completed by:

9.Your Relationship to the participant

11.Your Email Address

12.Emergency Contact

(who lives on a different address than participant)

13.Other Significant People in Participants Life

( Siblings, Aunt, Grandparents, Uncle, Friends Etc )

14.Disability / Medical Conditions including any diagnosis if relevant? (you will be required to provide emergency management plan when signing service agreement)

15.Mobility Assistance Required

16.What supports are currently in place for participant?

Independent Support Person

No Support

Others

If Independent Support Person then

What days do you have ISP?

If School Holiday Program / Yama Group

Enter School Details

What time slots/ days you are interested in?

Do you want to include Pick and Drop service

Yes

If Day Centre

What days you are looking for service?

Do you require transportation to and from service?

Yes

Are you interested in

Casual Booking

Regular Booking

If Respite/ Short Term accommodation

What days you are looking for service?

Do you require transportation to and from service?

Yes

Are you interested in

Casual Booking

Regular Booking

For participant below age of 19

For participant above age of 19

If Youth Employment Services

Is participant still in School?

Yes

What will be the graduation date for participant?

What subjects does participant find interesting?

Is participant involved in some extracurricular activities?

If Support Coordination is selected

Do you need a recovery coach?

Yes

What level of Support Coordination you require?

If Level 3 is selected then

Does your family has a history of family violence?

Yes

Does participant has significant Behaviour of Concern?

Yes

Is Level 3 Support coordination applied directly by Local Area Coordinator (LAC) at NDIS?

Yes

How many hours of Support Coordination do you have in your funding?

If participant is under 18

If participant is over 18

If SIL is selected

Does participant has a transition plan?

Yes

Does participant has active night?

Yes

Does participant has SIL Funding?

Yes

In Process

If In Process or No is selected

Do you have a Support Coordinator?

Yes

If yes

If No

Do you need a Support Coordination Services?

Yes

Do you have a Roster of Care in place

Yes

What type of SIL property you are interested in?

Independent Unit

Shared House

When does participant wants to move in ?

If Home Support is choosen

What days you are looking for service?

Do you want support in your home or want to go out in community?

Yes

Are you interested in

Casual Booking

Regular Booking

18.Participant Communication skills

Verbal

Non Verbal

Notes

If Non Verbal

What form of Augmentative and Alternative communication methods are in place?

Ipad

ALD

PECS

Visuals

Limited verbal responses

Sign language

Frequency of Use Note: Please indicate if any AAC is in use whether it is used at home and or at home and with other providers

20.Continence

Continent

Incontinent (wear nappies)

Notes (has accidents)

21.Do the participant has any allergies / Medical conditions

Yes

If Yes

Does participant has any of the following medical conditions

If Epilepsy / Asthma / Diabetes

Need to upload a plan

If Allergies

Does participant has an EpiPen?

Yes

If Yes

Where does he carry his EpiPen?

22.Is participant on any medication ?

Yes