Participant Referral Support Plan This Plan will Consist of: 1. Personal Information 2. Health and Medical 3. Safety Assessment Personal Services Requested Accommodation Tenancy Household Tasks Participation Community Specialised Driver Training Group Centre Activities Community nursing Managing life stages, transitions Daily Personal Activities Assistance Travel/Transport Daily Living and Life Skills Innovative Community Participation Shared Living Arrangement Employment or Higher Education NDIS Number First Name Last Name Date of Birth Phone Number Email Street Address City State / Province Postal / Zip Code Language Select Afghan Albanian Algerian American Andorran Angolan Antiguans Argentinean Armenian Australian Austrian Azerbaijani Bahamian Bahraini Bangladeshi Barbadian Barbudans Batswana Belarusian Belgian Belizean Beninese Bhutanese Bolivian Bosnian Brazilian British Bruneian Bulgarian Burkinabe Burmese Burundian Cambodian Cameroonian Canadian Cape verdean Central african Chadian Chilean Chinese Colombian Comoran Congolese Costa rican Croatian Cuban Cypriot Czech Danish Djibouti Dominican Dutch East timorese Ecuadorean Egyptian Emirian Equatorial guinean Eritrean Estonian Ethiopian Fijian Filipino Finnish French Gabonese Gambian Georgian German Ghanaian Greek Grenadian Guatemalan Guinea-bissauan Guinean Guyanese Haitian Herzegovinian Honduran Hungarian Icelander Indian Indonesian Iranian Iraqi Irish Israeli Italian Ivorian Jamaican Japanese Jordanian Kazakhstani Kenyan Kittian and nevisian Kuwaiti Kyrgyz Laotian Latvian Lebanese Liberian Libyan Liechtensteiner Lithuanian Luxembourger Macedonian Malagasy Malawian Malaysian Maldivan Malian Maltese Marshallese Mauritanian Mauritian Mexican Micronesian Moldovan Monacan Mongolian Moroccan Mosotho Motswana Mozambican Namibian Nauruan Nepalese New zealander Ni-vanuatu Nicaraguan Nigerien North korean Northern irish Norwegian Omani Pakistani Palauan Panamanian Papua new guinean Paraguayan Peruvian Polish Portuguese Qatari Romanian Russian Rwandan Saint lucian Salvadoran Samoan San marinese Sao tomean Saudi Scottish Senegalese Serbian Seychellois Sierra leonean Singaporean Slovakian Slovenian Solomon islander Somali South african South korean Spanish Sri lankan Sudanese Surinamer Swazi Swedish Swiss Syrian Taiwanese Tajik Tanzanian Thai Togolese Tongan Trinidadian or tobagonian Tunisian Turkish Tuvaluan Ugandan Ukrainian Uruguayan Uzbekistani Venezuelan Vietnamese Welsh Yemenite Zambian Zimbabwean Interpreter Required Select Yes No Participant Identify as Select LGBTIQA+ Aboriginal Aboriginal and Torres Strait Islander CALD Torres Strait Islander Normal People Interpreter Select Auslan TTL Assistive Technology Binary Normal People Guardian Details First Name Last Name Relationship with Participant Phone Number Email NDIS Plan Start Date NDIS Plan End Date Plan Manager First Name Plan Manager Last Name Plan Manager Email Does the Participant Live Alone? Yes No Is the Participant Supported by only one Worker? Yes No Support Coordinator First Name Last Name Email Phone Number Emergency Contact First Name Last Name Phone Number First Name Last Name Phone Number Medium - Term Goal Short - Term Goal Long - Term Goal Allergies / Alerts Primary Disability Secondary Health / Medical Conditions Is the Client at Risk of Choking, Seizures or Anaphyxalis Yes No Is assist with Medication Administration Required Yes No Does Client Suffer from Irritants, Phobias or any other Specific Condition Yes No Do you give consent to share this form with your Support Network, other providers. and Relevant Government Agencies? Yes No Describe the Support Required Is this Home easy to Locate? Yes No Is Onsite / Street Parking Available for Support Worker's Car Yes No Are any Gates or Doorways Difficult to use or Access Yes No At night, is the House Entrance Hard to Find Yes No Are there any Slip, Trip or Failing Hazards Outside the Home Yes No Is the Home Wheelchair Accessible Yes No Will the Support Worker be required to use any Electric Appliances Yes No In case of any emergency in the home, please describe the emergency procedure for the support worker to follow. Please consider any special procedures, nearest exits and emergency meeting points Is there anything else you would like to share about the home NOTE: It is the participant's responsibility to ensure certain safety requirements Electrical appliances and power cords are in good working order. Power cords are attached to power boards and power sockets, and not double adapters The house is fitted with a safety switch Support workers will not be exposed to cigarette smoke in the home Are there any places, situations or specific irritants that should be avoided Please provide details on how to manage this risk. Describe in detail if there is any way to avoid If something goes wrong in the community, are there any specific emergency instructions for the support worker Is there a risk that participant may abscond Yes No What type of transport participant will use? Please tick the relevant. Select Public Transportation Using the Participant's Car (with the support worker driving) Using the Support Worker's Car Are there any specific risks associated with transport Are there any specific risks associated with transport Do you give consent for the support worker to proactively support you in attending medical, and allied health services? Yes No Better Capacity Access Care will take reasonable efforts to work with the participant in selecting the preferred support worker Date / Time Send
