Participant Intake and Support plan

Participant Intake and Support plan
Please note this is a 'live' form and will be edited as required to stay relevant to the participant's needs.
Once you have entered the applicable information please list your email below to get an 'editable' copy, each person with an email listed will receive any updates.
Date this Participant Intake and Support Plan was started
DayMonthYear
2 digit day, 2 digit month, 4 digit yearPlease select the date this plan/ form was started.
Section 1: Personal details
Legal Name
First NameLast Name
Preferred name
Date of Birth
DayMonthYear
2 digit day, 2 digit month, 4 digit year1
Participant Address
street number, street name, town/ suburb, state, postcode
Place of birth
Previous names used
(if applicable)
Gender
Background
Primary Disability/ Existing conditions
Any health, medication, environmental, safety risk, emotional/behavioural, cognitive/developmental, mobility, nutrition, or dietary conditions relevant to the participant’s care.
Where possible, obtain management plans for these conditions (e.g. health plan, behaviour management plan, epilepsy plan, asthma plan, allergy plan).
Participant contact details
Mobile/ House number
Participant Email
example@example.com
Preferred method of contact
Guardian or Advocate Details
For participants under the age of 18 years, under guardianship or in the care of family or caregivers please complete below.
Guardian or Advocate Legal Name
First NameLast Name
Relation to participant
Guardian or Advocate Contact number
Guardian or Advocate Email
example@example.com
Guardian or Advocate Address
street number, street name, town/ suburb, state, postcode
Emergency Contact Details
Must be contactable outside business hours
Is the Emergency contact already listed as the participants guardian or advocate? if yes, do not fill out this information, please refer to the above section.
1st Emergency contact name
Mobile number
Relation to participant
Address
street number, street name, town/ suburb, state, postcode
2nd Emergency contact name
Mobile number
Relation to participant
Address
street number, street name, town/ suburb, state, postcode
Section 2: NDIS Plan Details
Participant NDIS Number
Current NDIS Plan Start date
DayMonthYear
2 digit day, 2 digit month, 4 digit year2
Current NDIS Plan Finish date
DayMonthYear
2 digit day, 2 digit month, 4 digit year3
Section 3: Participant needs and preferences
Participant needs and preferences regarding their supports. Consider physical, emotional, spiritual, cultural, social and health/medical needs.
Specific support requests are required further down.
The participant’s living skills; and any daily routine they may have including eating, drinking, dressing, sleeping, bathing, toileting:
Example: Participant needs assistance to eat breakfast as per dietician report attached and has a shower everyday before bed.
Likes and dislikes:
Example: Participant likes cereal for breakfast, decaf coffee. Dislikes wearing long pyjama pants to bed and watching the news on tv.
The participant’s education, training and/or vocational needs, goals and preferences:
Example: Participant learns best when shown a task repetitively over a period of days or weeks. Participant benefits from drawings or pictures to help him understand.
The participant’s social and/or leisure preferences:
Example: Participant enjoys a daily walk and likes to visit a restaurant on Friday evenings for a meal. Participant has day program x3 per week on Monday's, Wednesday's and Thursday's.
Section 4: Communication needs
Please list the participant communication needs, including details of any communication aids that are required. Please refer to the participants Communication Plan when possible.
Section 5: Behaviours of concern
Behaviours of concern are determined by the Behaviour Support Specialist. If this is relevant for the participant, outline how behaviours of concern will be managed. Please refer to the Positive Behaviour Support Policy, Refer a Participant to a Behaviour Support Specialist Procedure and Behaviour Support Plan (provided by the Behaviour Support Specialist).
Section 6: Participant's Required Assistance with Activities of Daily Living (ADLs) and Mobility
Assistance with ADLs: Showering, toileting, dressing, grooming (Please include use of incontinence aids if applicable).
Mobilities needs and equipment: Hoists, walking aids, transfer aids, shower/toilet aids.
Section 7: Support provision information
Identify the types of support you would like GO Care to provide
Shift specific questions
Who should we notify if there is a change to your scheduled shift?
Example: Myself (Participant), Next of Kin, Support coordinator, Advocate/ Guardian
How should we make contact about urgent shift changes?
If your regular shift booking falls on a public holiday do you still require support as per your regular booking/ schedule B?
Are you comfortable meeting a new support worker to assist you if your regular team is unavailable for your requested time/shift?
Is Agency Use Permitted? or do you use other providers we can contact to assist in providing coverage for your shift with GO Care?
Please contact these other providers if GO Care are unable to fill my shift.
Section 8: Risk assessment
To be completed by GO Care Team Leader.
Please upload a copy of the Participant's completed risk assessment form
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Section 9: Care plan
Based upon the Participants NDIS goals
List NDIS Goals
Section 10: Participant Arrangements
Provide information on arrangements required for the participant, such as periodical appointments for vaccinations, dental care, doctor visits and allied health services.
Examples for Arrangement Types: Periodical GP, Dentist or Allied Health Appointments.
Section 11: Allied Health Information
Information of medical practitioners involved in supporting the participant. This includes proactive support for preventative health measures (e.g., dental, vaccinations etc)
Section 12: Medical Complications
Provide information on participant complications, any signs and symptoms that may occur and action/s required in response.
Section 13: Emergency management information
To be completed by GO Care Team Leader.
Attach any relevant emergency information such as, flow charts or doctor’s instructions that are specific to the participant. Please refer to the Health and Wellbeing Procedure, Hospital Planning Admission Procedure, The Person We Support Needs Urgent Help Procedure and the Participant’s Individual Hospital Transfer Folder.
Section 14: Emergency and Disaster management information
To be Completed by the GO Care Team Leader.
GO Care Team Leader to attach any relevant emergency information such as the participant’s individual Redi plan and the participant’s individual Emergency and Disaster Management plan. For Medical Emergencies please refer to section 13.
File Upload
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Section 15: Communication plan
How relevant information in this plan will be communicated to the participant’s support network, other providers and government agencies. Refer to the Working with Participant Support Network Policy, Working with Participant Support Network Procedure and the Participants Individual Health Passport. To be completed by GO Care Team Leader.
File Upload
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Please list the Support Networks that we communicate with for this participant.
Section 16: Worker training arrangements
To be Completed by the GO Care Team Leader.
Record details about training type and timeframes associated with training of support workers. (Example: Training for medical complication and Emergency response. 12 monthly update required)
Relevant Documents
Please provide a copy of the following documents that are relevant to the participant. (Please place a mark in the relevant information’s box)
Other
Please describe 'other' documents provided.
Attach Files Here
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Section 17: Authorisation to use image
For Go Care support services community and promotional activities.
For good and valuable consideration, the receipt of which is hereby acknowledged, I hereby consent to the photographing of myself / above person and the recording of my/his/her voice and the use of these photographs and/or recordings singularly or in conjunction with other photographs and/or recordings taken by Go Care Support Services for community and /or promotional activities, publicity, commercial or other business purposes.
I understand that the term "photograph" as used herein encompasses both still
photographs and motion picture footage.
I further consent to the reproduction and/or authorization by GO Care Support Services, 71 Drummond Street, Warrnambool, VICTORIA, to reproduce and use said photographs and recordings of voice, for use in all domestic and foreign markets.
I hereby release GO Care Support Services, and any of its associated or affiliated companies, their directors, officers, agents, employees and customers, and appointed advertising agencies, their directors, officers, agents and employees from all claims of every kind on account of such use.
I have read and understand the above, and therefore consent:
Section 18: Signatures and Section 19: Details of plan developers
All parties involved in providing input to this document must list their details and signature.
Name of Participant
Participant Signature
When Should a Guardian or Advocate Sign this Form on behalf of a participant?
A guardian should sign if the participant is under 18 years of age or has a legal guardian appointed.
An advocate should sign if the participant has authorized someone to act on their behalf in decision-making or communication.
Advocates/guardian’s Name
relationship to the participant
Date plan was created or edited:
DayMonthYear
2 digit day, 2 digit month, 4 digit year4
Advocates/guardian’s signature
GO Care Representative’s Name
Date plan was created or edited:
DayMonthYear
2 digit day, 2 digit month, 4 digit year5
GO Care Representative’s Email
GO Care Representative’s signature
People involved in the creation of this document.
Name of Person/ Developer:
Date plan was created or edited:
DayMonthYear
2 digit day, 2 digit month, 4 digit year6
Relationship to the participant
Developer Email
Signature of developer
Name of Person/ Developer(2):
Date plan was created or edited:
DayMonthYear
2 digit day, 2 digit month, 4 digit year7
Relationship to the participant
2nd Developer Email
Signature of developer
Name of Person/ Developer(3):
Date plan was created or edited:
DayMonthYear
2 digit day, 2 digit month, 4 digit year8
Relationship to the participant
3rd Developer Email
Signature of developer
Name of Person/ Developer(4):
Date plan was created or edited:
DayMonthYear
2 digit day, 2 digit month, 4 digit year9
Relationship to the participant
4th Developer Email
Signature of developer
Name of Person/ Developer(5):
Date plan was created or edited:
DayMonthYear
2 digit day, 2 digit month, 4 digit year10
Relationship to the participant
5th Developer Email
Signature of developer

Name	Position	Responsibilities	Contact Information
Gerard O’Brien	Director	Culture, Invoicing	0430 003 174
Kaoru O’Brien	Chief Executive Officer	Vision, future planning, Participant/Worker Relations, Feedback, Complaints	0401 070 236
Susanna Bevilacqua	Operations Manager	Business and strategic planning/management, Feedback, Complaints	0472 782 808
Chris Mwaura	SIL & Respite Team Leader	Residential Support, SIL and Respite relations and staff; services planning/management, Feedback, Complaint	0460 415 308
Stephen Gabriel	SIL & Respite Team Leader	Residential Support, SIL and Respite relations and staff; services planning/management, Feedback, Complaint	0472 668 704
Amber Furlong	Individual Supports Team Leader	Individual Support relations and Staff	0459 494 884

Should be Empty:

Participant Intake and Support plan

Section 1: Personal details

Guardian or Advocate Details

Emergency Contact Details

Section 2: NDIS Plan Details

Section 3: Participant needs and preferences

Section 4: Communication needs

Section 5: Behaviours of concern

Section 6: Participant's Required Assistance with Activities of Daily Living (ADLs) and Mobility

Section 7: Support provision information

Section 8: Risk assessment

Section 9: Care plan

Section 10: Participant Arrangements

Section 11: Allied Health Information

Section 12: Medical Complications

Section 13: Emergency management information

Section 14: Emergency and Disaster management information

Section 15: Communication plan

Section 16: Worker training arrangements

Relevant Documents

Section 17: Authorisation to use image

Section 18: Signatures and Section 19: Details of plan developers