Care Questionnaire
Participant Details
Participant Name
First Name
Last Name
Participant Preferred Name
Date of Birth
-
Month
-
Day
Year
Date
Address
Street Address
Street Address Line 2
City
State
Post code
Email
Please enter a valid email address.
Phone Number
Please enter a valid phone number.
Format: 0400 000 000.
Gender
Please Select
Female
Male
Non-binary
NDIS Number
Type of Supports Required (list multiple if required)
Supported Independent Living
Community Access Support
Drop-in Support
**Section begin - Funding
Does the applicant have funding in your current plan specifically for SIL?
Yes I do.
Not yet, still awaiting approval
No, I'm not eligible for SIL funding.
**Section end - Funding
**Begin - Service managed?
How is the participant's care currently managed?
NDIS managed
Self-managed
Plan managed
Other
**End - Service managed?
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Primary Contact
Contact Name
First Name
Last Name
Relationship to applicant
Please Select
Guardian
Carer
Mother
Father
Other Family Member
Other
Contact Email
example@example.com
Phone Number
Please enter a valid phone number.
Format: 0400 000 000.
Contact Mailing Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Preferred method of contact
Phone call
Email
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Participant Care Information
Participant's Diagnosis (help us match you with the most suitable carer)
Participant Allergies
Participant Medications
** begin - medications
Do medications need to be taken on shift?
Yes
No
** end - medications
Communication Assistance Required?
Yes
No
Care Management Specifics
N/A
Complex Bowel Care
PEG - Internal Feeding
Tracheostomy Management
Urinary Catheter Management
Ventilator Management
Subcutaneous Injections
Complex Word Management
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Participant Character Details
About Me
Tell us some information about the participant. GE: Family, experiences, friends, school etc etc
Personal Goals
Tell us your Aspirations / Aims / Wants
Interests
Tell us about your likes, hobbies and interests
Tell us about your dislikes.
Tell us about potential triggers and dislikes
Other important things to note
i.e: leave shoes at door / cats at home and carer required not to be allergic
Support Worker Preference Profile
Tell us about the type of person you would like looking after the participant
Submit
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