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HELP AID
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Referral
We won’t talk to anyone else about you unless you say so!
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REFERRER INFORMATION
Date of Referral
Name
*
First
Last
Position
Organisation
Phone
*
Email
*
Preferred means of communication:
Funding Manager
Select
Plan Managed
Self Managed
NDIA Managed
Plan Manager’s Details
Start Date
End Date
Current Funding Available for Services Required
PARTICIPANT INFORMATION
All about you!
Name
*
Birth Date
NDIS Participant Reference Number
Gender
Male
Female
Non-Binary
Address
Address Line 1
Address Line 2
City
State / Province / Region
Postal Code
Any specific access details to the property
Phone
Email
*
Country of Birth & Language Spoken
Translator Required
Yes
No
Clinical Diagnosis
Current Prescribed Medications
Select
Yes
No
If yes, please attach a list
Do you require medication administration support?
Select
Yes
No
Do you have a current Positive Behaviour Support Plan in place?
Select
Yes
No
Do you have a mealtime management plan?
Select
Yes
No
Medical Conditions:
Do you experience seizures?
Select
Yes
No
If YES, do you have a current seizure plan?
Layout
Allergies
Epi Pen Prescribed?
Select
Yes
No
What level of support do you require when undertaking the following activities?
What level of support do you require when undertaking the following activities?
Personal Care
Select
1:1
Independent
Eating
Select
1:1
Independent
Toileting
Select
1:1
Independent
Mobilising
Select
1:1
Independent
In the community
Select
1:1
1:2
1:3
1:4
Independent
Overnight
Select
1:1
1:2
1:3
1:4
Independent
Is there any other specific support you need?
Layout (copy)
GP Name
GP Contact Number
EMERGENCY CONTACT
Who do you want us to call if there is an emergency?
Name & Relationship:
Address
Address Line 1
Address Line 2
City
State / Province / Region
Postal Code
Phone
LEGAL GUARDIAN
Is there somebody who helps you make decisions?
Name & Relationship
Address
Address Line 1
Address Line 2
City
State / Province / Region
Postal Code
Phone
ADDITIONAL INFORMATION
Are there some other documents and reports that will help us to help you?
Recent Occupational Therapy Report
Select
Yes
No
Current GP Care Plan
Select
Yes
No
Mealtime Management Plan
Select
Yes
No
Current Mental Health Care Plan
Select
Yes
No
Other
Select
Yes
No
RISK ASSESSMENT
What do we need to know to keep you, our staff and the community safe?
Choking / Dysphagia
Select
Yes
No
Comment
Level of Risk
Field #74 (copy)
History of Aggression / Violence
Select
Yes
No
Comment
Level of Risk
Field #74 (copy) (copy)
Absconding behaviours
Select
Yes
No
Comment
Level of Risk
Field #74 (copy) (copy) (copy)
Substance Abuse
Select
Yes
No
Comment
Level of Risk
Field #74 (copy) (copy) (copy) (copy)
Poor sense of road traffic safety / Uncomfortable crossing major roads
Select
Yes
No
Comment
Level of Risk
Field #74 (copy) (copy) (copy) (copy) (copy)
Inappropriate sexualised behaviours
Select
Yes
No
Comment
Level of Risk
Field #74 (copy) (copy) (copy) (copy) (copy) (copy)
Psychiatric Illness
Select
Yes
No
Comment
Level of Risk
Field #74 (copy) (copy) (copy) (copy) (copy) (copy) (copy)
Threatening / Argumentative Behaviour
Select
Yes
No
Comment
Level of Risk
Field #74 (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy)
Criminal History
Select
Yes
No
Comment
Level of Risk
Field #74 (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy)
Animals in the home
Select
Yes
No
Comment
Level of Risk
Field #74 (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy)
Tenancy Issues
Select
Yes
No
Comment
Level of Risk
Field #74 (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy)
Smoking
Select
Yes
No
Comment
Level of Risk
Field #74 (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy)
Self-Harm Behaviours
Select
Yes
No
Comment
Level of Risk
Field #74 (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy)
Medication Non-Compliance
Select
Yes
No
Comment
Level of Risk
Field #74 (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy)
Falls are common
Select
Yes
No
Comment
Level of Risk
Field #74 (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy)
Other
Select
Yes
No
Comment
Level of Risk
Submit
