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03 9131 4642
OFFICE HOURS
MON–FRI: 09:00–17:00
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Carer or participant representative information
First Name
Preferred Name (if different)
Last Name
Relationship to Participant
Parent
Legal Guardian
Primary Carer
Family member
Case Manager
Other
if other, please describe
Phone number
Email
Preferred contact method
Email
Phone
Participant information
First Name
Preferred Name (if different)
Last Name
Address
Suburb
State
ACT
NSW
QLD
SA
VIC
WA
Postcode
Date of Birth
Phone number
Email
Preferred contact method
Email
Phone
Gender
Male
Female
Language spoken at home
Living situation
Own home
Own home / living with family
Rent home
Rent home / living with family
Live with parents / family
Support accomodation
Self managed, Plan Managed or NDIA managed
Self Managed
Plan Managed
NDIA Managed
NDIS number
Plan Details
Self managed
Portal managed
Plan management provider
Other
Plan management provider details
Disability diagnosis and severity / medical conditions / other necessary health information
Services Required
Assistance with Self Care Activities
Community, Social and Recreation Access
Employment Support
Respite / Short Term Accommodation
Personal care - assistance required with:
Showering / bathing
Toileting
Dressing
Grooming
Bowel care (Enemas/Suppositories)
Leg bag care
PEG feeding
Wound care
Other
Mobility - assistance required with
Walking - independent
Walking - assisted
Walking frame
Walking stick
Wheelchair - electric
Wheelchair - manual
Hoise transfers
Shower chair
Other
Communication
Verbal
Non-verbal
Communication Aid
Other
Cognition
Very Good
Good
Fair
Poor
Behavioural support plan ?
Yes
No
In the process
If yes, please describe behaviours or upload behavioural plan
Upload behavioural plan
Do you require specific shift times?
Do you have any Support Worker preferences?
Do you have any short term or long term goals?
Is there anything else we should know?
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