Request for Support Form

Participant Details

Name of Participant *

Preferred Name:

Date of Birth *

Gender *

Female Male Intersex or Indeterminate

Address: *

Street address *

City *

State

Postcode

Email Address:

Contact Number:

NDIS Number: *

NDIS Plan Dates: *

Please Provide NDIS Goals *

Consent and Decision-Making

Participant Capacity *

Own Decision Maker and NDIS Plan Nominee Own Decision Maker - Supported by a NDIS Plan Nominee Appointed a Public Guardian (OPG)Appointed a Enduring Power of Attorney

If assisted Decision Making - Please provide name of entitled person:

Best contact number/email:

Emergency Contact/ Next of Kin

Name: *

Relationship *

Contact number: *

Email Address: *

Support Coordinator Details

Name: *

Contact Number *

Email: *

Support Request Details

Specify Times and/or Hours: I.e., 9am-1pm *Provide as much detail as possible to better access capacity.

Request for SIL *

Yes No

Request for STA/MTA *

Yes No

What does the person want/need support with? *

Funding Type

Funding Type *

Agency Managed Plan Managed Agency and Plan Managed Self-Managed

If Plan Managed - provide Plan Manager name:

Email address for invoicing: *

About Participant

What type of disability/disabilities does the individual have? *

Physical Profile

Weight (kg)

Height (cm)

Facial Hair

YesNo Prefer not to say/Unknown

Birth marks

Yes No Prefer not to say/Unknown

Tattoos

Yes No Prefer not to say/Unknown

Culture, Communication & Intimacy:

Preferred Language/dialect: *

Interpreter required? *

YesNo

Cultural values/ beliefs or assumptions: *

Are there any cultural, communication barriers or intimacy issues that need to be considered when delivering services? *

YesNo

If Yes, specify

Cultural behaviours:

Living and support arrangements

Travel

How does the individual travel to work or to their day service? *

Taxi Pick up/ drop off by Parent/Family/Support PersonTransport provided by a providerIndependently use Public TransportWalk Assisted Public TransportDrive own car Other

If other, please specify:

Profile Information

What are their likes/strengths: *

What are their dislikes/ challenges: *

What might trigger them/ make them anxious?

Support Worker preference

Any preference for the Support workers’ gender? *

Male Female NIL preference

What are important qualities in a support worker and what don’t they like? *

Medication Information/Health Details

Does the individual take any regular medication? *

Yes NoUnknown

Do they require support/supervision with medication management? *

Yes No

If other, please specify below:

Does the individual have any allergies? *

Please specify warning signs/symptoms and immediate actions required:

GP/Doctor Details (incl. Name, Practice Name, Phone Number) *

Safety Considerations

Is the individual prone to falls or have history of falls? *

Yes No Unknown

Does the participant require any physical assistance i.e., transfers *

Yes No Unknown

Is there a current Forensic or Treatment Order in place? *

Yes - Treatment OrderYes - Forensic OrderNo Unknown

Are there any signs, or a history of, respiratory depression? *

Yes No Unknown

Weekly schedule of activities/ routine/ Appointments that we should be aware of?

Monday (Activity, Start - Finish, any details)

Tuesday (Activity, Start - Finish, any details)

Wednesday (Activity, Start - Finish, any details)

Thursday (Activity, Start - Finish, any details)

Friday (Activity, Start - Finish, any details)

Saturday (Activity, Start - Finish, any details)

Sunday (Activity, Start - Finish, any details)

Name of person completing this form: *

Signature of person completing this form. *

Draw signature|Type signatureClear

Date: *