Client Name *

Date of Birth:

Registration Number:

Type of NDIS Funding:
Agency ManagedSelf ManagedPlan Managed

Specify Plan Manager (if applicable); refer to NDIS Funding
Type

Address

Phone Number

Email

Preferred Contact Method
PhoneEmailMailSMS

Name *

Client Relationship

Address

Phone Number

Email *

Preferred Contact Preference
PhoneEmailMailSMS

Living Arrangements
Living Independently (Solo)Living with Family in Own HomeAssisted Living ArrangementsTemporaryOther

Are you of Aboriginal or Torres Strait Islander
descent?
Please selectYesNo

Does the Client Currently Have a Behavioral Support
Plan?
Please selectYesNo

Main Formal Diagnosis

Secondary Formal Diagnosis

Do you have any allergies? If so, please specify
below.

Please list all medical diagnoses and medications that may
impact the support provided.

Please provide the name and contact number of the client's
doctor.

Please disclose any legal issues that may impact the service,
such as Apprehended Violence Orders.

Type
Please selectVerbalNon-VerbalRequired Communication AidsOther

Are you from a culturally or linguistically diverse
background?
Please selectYesNo

Is there any cultural diversity, values, or beliefs you'd
like us to be aware of?
Please selectYesNo

Languages Spoken
EnglishOther

Is an interpreter needed?
NoHearing ImpairedLanguage

Are you willing to participate in and consent to the use
of...
Goal Data PhotosSocial Media PhotosWebsite PhotosParticipating in audits conducted by the NDIS Commission for our business, including...its auditorsThe recording of your personal information in audio and/or visual formatNone of the above

No Dietary Needs
YesNo

Vegetarian
YesNo

Vegan
YesNo

I have allergies to (please list)

I cannot consume (sensory/intolerances)

My favourite food is…

Disability Services 24/7 can assist me during mealtimes
by...
I can identify which foods are safe for me to eat (if required due to allergy or dietary requirements).If I have a food allergy, I have provided Disability Services 24/7 with a management plan.If necessary, I will bring any medications to assist with my allergy and have completed the relevant medical forms.I prefer to provide my own food and will do so.

I have/experience…
DepressionAnxietyPsychosisSchizophreniaBipolarOther

I would like Disability Services 24/7 to assist me in
managing this by...

My triggers may include…

I am supported/linked with the following organizations who
assist me... (Please supply relevant management plans.)

I have received medical support to assist me, and Disability Services 24/7 has a copy of any relevant management plans to help me manage.

I have…

Allergies to:

I am taking the following medications:

Medication List:

I would like Disability Services 24/7 to assist me in managing this by...

Traffic awareness
I can do independentlyI need some assistance.I cannot do independently

Staying with the group
I can do independentlyI need some assistance.I cannot do independently

Appropriate Communication
I can do independentlyI need some assistance.I cannot do independently

Personal Space Awareness
I can do independentlyI need some assistance.I cannot do independently

Respecting Personal Boundaries
I can do independentlyI need some assistance.I cannot do independently

Safe Car Travel
I can do independentlyI need some assistance.I cannot do independently

Following Instructions
I can do independentlyI need some assistance.I cannot do independently

Swimming and Water Safety
I can do independentlyI need some assistance.I cannot do independently

I can manage my own spending money.
I can do independentlyI need some assistance.I cannot do independently

I am comfortable with my sleeping routine.
I can do independentlyI need some assistance.I cannot do independently

Swimming and Water Safety
I can do independentlyI need some assistance.I cannot do independently

Disability Services 24/7 can assist me by…

I have provided Disability Services 24/7 with any relevant behavior plans for assisting me when required.

My strengths are (what I am good at)…

I like…

I don’t like… (please include any sensory considerations)

You will know when I am happy by…

You will know when I am unhappy by…

I prefer to communicate by…

How have these goals changed since your previous Support Plan (if applicable)?

How does your existing support from us or other providers help achieve desired outcomes? Is there any opportunity to use less intrusive options, in accordance with contemporary evidence-informed practices that meet participant needs and help achieve desired outcomes?

Activity
Continence with regular bowel and bladder functionManagement of Constipation, Diarrhea, or Incontinence (including medication, supplements, pads)Medical Interventions (such as catheter, stoma bag)

Outline the condition, treatments, aids/assistance required, who will provide them, and when.

Skin Health
No Skin IssuesMinor Skin Issues (rash, skin treatments)Pressure Sores (current, at risk, or history)

Please outline the condition, required treatments, aids/assistance needed, who will provide them, and when.

Swallowing Function
No Swallowing DifficultiesMinor Swallowing Issues (choking, coughing during meals, reduced appetite)Severe Swallowing Difficulties (modified diet, feeding tube)

Please outline the condition, required treatments, aids/assistance needed, who will provide them, and when.

Healthcare Professionals
Received a GP check-up in the last 12 monthsRegularly visit a specialistHave a Case Manager/Support Coordinator

Please outline the condition, required treatments, aids/assistance needed, who will provide them, and when.

Muscular pain
No painModerate PainSevere Pain

Please outline the condition, required treatments, aids/assistance needed, who will provide them, and when.

Nerve pain
No PainModerate PainSevere Pain

Please outline the condition, required treatments, aids/assistance needed, who will provide them, and when.

Falls Risk
No Falls in Past 12 MonthsLess Than 3 Falls with No Serious Injury in the Past 12 MonthsMore Than 3 Falls or Serious Injury from a Fall in the Past Year

Please provide details of the condition, necessary treatments, required aids/assistance, who will provide them, and when.

Muscle-related Issues (excluding pain)
No problemsMuscle Weakness, Tremors, Spasms, Spasticity, or Balance IssuesSevere Muscle Weakness, Tremors, Spasticity, or Balance Issues

Please provide details of the condition, necessary treatments, required aids/assistance, who will provide them, and when.

Other Health Issues
FatigueVisual DisturbanceTemperature IntoleranceOther Medical Conditions

Please provide details of the condition, necessary treatments, required aids/assistance, who will provide them, and when.

Describe how you would like to engage in this activity.

Please provide details of the activity, including the time spent, assistance required, who will provide it, and when (including vouchers).

Describe how you would like to engage in this activity.

Please provide details of the activity, including the time spent, assistance required, who will provide it, and when (including vouchers).

Please describe how you would like to engage in this activity.

Please provide details of the activity, including the time spent, assistance required, who will provide it, and when (including vouchers).

Describe how you would like to engage in this activity.

Provide details of the activity, the time spent, the assistance required, from whom and when (including vouchers)

Outline how you want to engage in this activity

Provide details of the activity, the time spent, the assistance required, from whom and when (including vouchers)

Outline how you want to engage in this activity

Provide details of the activity, the time spent, the assistance required, from whom and when (including vouchers)

Outline how you want to engage in this activity

Provide details of the activity, the time spent, the assistance required, from whom and when (including vouchers)

Outline how you want to engage in this activity

Provide details of the activity, the time spent, the assistance required, from whom and when (including vouchers)

Outline how you want to engage in this activity

Provide details of the activity, the time spent, the assistance required, from whom and when (including vouchers)

Outline how you want to engage in this activity

Provide details of the activity, the time spent, the assistance required, from whom and when (including vouchers)

Outline how you want to engage in this activity

Provide details of the activity, the time spent, the assistance required, from whom and when (including vouchers)

Outline how you want to engage in this activity

Provide details of the activity, the time spent, the assistance required, from whom and when (including vouchers)

Outline how you want to engage in this activity

Provide details of the activity, the time spent, the assistance required, from whom and when (including vouchers)

Communication
Please selectNo assistance required (including independent use of aids and adaptive technology)Some assistance required (prompting, assistance with aids)Assistance always required

Outline the issue, aids, assistance, and management strategies required