Respite Case Notes Form
Full Name of Client
*
First Name
Last Name
Full Name of Experience Curator
*
First Name
Last Name
Pre Respite Contact
Please concisely detail the pre-respite conversations with the client. At a minimum there should be two pre contacts, initial call and pre respite call.
Date of first contact
*
 -
Month
 -
Day
Year
Date
Provide a brief description of the first contact conversation
Date of second contact
*
 -
Month
 -
Day
Year
Date
Provide a brief description of second contact conversation
*
Please detail any further contacts with the client pre-respite, please provide the date and details of contact, for example, 10/01 - client confirming what to pack.
Respite Details
Please provide details of the respite stay.
Pick up date and time to the closest hour.
Case Notes
Please write your case notes per day and include the following. Narrative on the day, guest presentation, interactions and any work undertaken to support the client, for example, grounding activities.
Risk
Please use this section to identify any additional risks identified through the respite stay, please only add new risks that have not been identified in the Getting to Know You Assessment.
Type of risk identified
*
Alcohol/Drug Use
Allergies or food intolerances
Self Harm
Suicide (history, ideation or Intent)
Mechanical or Mobility Risk
Violence to Others
Other
None
Please provide further detail if you have identified an additional risk:
Travel
This is travel to and from a respite stay
1:1 - Number of KM's travelled
*
1:2 - Number of KM's travelled
*
1:3 - Number of KM's travelled
Transport
This is transport during a respite stay after you have arrived at the experience location, this does not include the journey home at the end of the stay.
1:1 - Number of KM's travelled
*
1:2 - Number of KM's travelled
*
1:3 - Number of KM's travelled
Submit
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