Support Work Intake Form

About You

Your Full Name

Your Email Address

Your Mobile Number

Your Relationship to the Participant

About the Participant

Gender

Preferred Pronouns

Full Home Address

123 Step Road, Waurn Ponds VIC 3216

Funding Management Type

Days Support is Required

Time of Support on chosen days

Allergies

"Allergic to pineapple, gets a rash on skin"

Does the participant have a Behaviour Support Plan?

Does the participant have a seizure management plan?

Does the participant have an Asthma management plan?

Does the participant have an Anaphylaxis management plan?

About Supports

What goals should be worked on during support?

What should support look like/what would you like to take place during support?

How do you typically communicate your needs when upset or overwhelmed?

Do you have any specific triggers? Sensory, demand avoidance, overwhelm, anxiety ect

Are there any games, activities, interests or hobbies that can be incorporated?

How do you typically handle transitions from one task to another? What helps/doesn't help?

Are there any challenging behaviours we should know about?

Can include hitting, kicking, biting, screaming/yelling, crying, running away

Are there any safety concerns or medical considerations we should know about?

Do you require any physical assistance?

With walking, showering/self care, moving from ground to car ect

Do you have any particular communication needs?

Simple English, Key Word Sign, PDA Friendly Language, AAC Devices

What is your sense of road safety like? Are you safe to travel in a vehicle?

If the participant is a child, is a car seat required?

Will medication need to be administered during supports?

Risk Assessment

In the event of a natural disaster, does the participant require our assistance? (Outside of shift times)

For example: Supports are on Mondays only and there is a bushfire on Tuesday. Is support from us required?

Does the participant/household have an emergency management plan/evacuation plan/fire evacuation plan?

What type of premises is the home address?

Is the street sign or property number easy to see?

If visiting after dark, is the property well lit?

Where can we park?

If there is a gate, is it difficult to open?

Are there any dangerous/uneven paths leading to the house?

Are there any dangerous or slippery steps?

Are there any animals with open access to the front yard of the property, or will be unrestrained inside the house?

Is it likely that any people in the home will be smoking or drinking alcohol during our visit?

Does anybody smoke inside the house?

Is the participant or anyone in the house undergoing Cytotoxic treatment? (E.G Chemotherapy)

Is there any known substance use amongst people who may be present?

Are there any known weapons/guns in the house?

Is Child Protection involved in the families support?

We ask these questions with care, not judgement. Nothing you share here will affect your access to supports - our only goal is understanding your family's full picture so we can provide the safest, most appropriate care possible.

Are there any specific triggers, environments, or people our staff should avoid or be alert to?

Anything else we should know?

Emergency Planning

Would you like to opt out? (Opt out means not fill out the emergency plan!)

Medical

GP Name, Clinic, Phone Number

Nearest/Preferred Hospital

Current Medications

Please include name, dose, frequency, & location in home

Any medical conditions requiring emergency-specific response (epilepsy, anaphylaxis, diabetes, cardiac conditions etc)

Epipen or emergency medication on person?

Ambulance Cover?

Emergency Contacts

Emergency Contact #1

Name, Relationship, Phone Number

Emergency Contact #2

Name, Relationship, Phone Number

Specific Emergency Instructions

Is there anything workers must know in an emergency specific to this participant? (communication needs, sensory considerations, medication instructions, what calms them down if distressed)

Does the participant have a current emergency management plan from another provider or hospital? Yes/No - if yes, copy on file?

Life Support and Medical Equipment

Does the participant use any life support or medical equipment at home?

Medical Alert Information

Does the participant wear a medical alert bracelet or carry a medical alert card?

Does the participant have a MedicAlert or similar service subscription?

Does the participant have a hospital care plan or emergency protocol document on file?

Communication in an Emergency

If the participant is non-speaking or has complex communication needs, how do they communicate distress or pain?

Is there an AAC device, communication board, or other system workers should know about in an emergency?

Do you need anything from us in case of an emergency? (Fire, natural disaster, pandemic)