ILO STARTING QUESTIONS
My Supports has developed this document to help initiate the ILO Exploration and Design stage
Please answer each of the sections below form.
PARTICIPANT INFORMATION
Name
*
First Name
Last Name
NDIA Number:
*
Phone Number
*
Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
Suburb
State
Post Code
Gender
*
Date of Birth
*
How did hear about My Supports?
Search Engine (Google, Yahoo, etc.)
Social Media
Printed advertisement
Word of Mouth
Other
Does the participant require a guardian/registered nominee to maker decisions/sign on their behalf?
*
Yes
No
CONTACT DETAILS
Contact Details of Person Completing this Form
*
First Name
Last Name
Relationship to the participant
*
Phone
*
Email
*
example@example.com
Additional Contact Information
Contact 1. (e.g. Registered Nominee / Guardian etc)
First Name
Last Name
Relationship to Participant
Phone Number
Email
example@example.com
NDIA Planner / LAC Contact Information:
*
First Name
Last Name
Phone Number
*
Email
*
example@example.com
PARTICIPANT INFORMATION
Participant Goals (relating specifically to accommodation and living supports):
*
Participant's disabilities:
*
Is a functional assessment available?
*
Yes
No
Participant's Medical Conditions: (if any)
Is a Care Plan available?
*
Yes
No
Is there a Medication Plan available?
*
Yes
No
Is a Behaviour Support Plan available?
*
Yes
No
Are any Restrictive Practices in place?
*
Yes
No
Please list the behaviours of concern and frequency (including as listed in Behaviour Support Plans) Please include any restrictive practices in place, if any:
Do you want "In Home Supports" included in your ILO Arrangement?
*
Yes
No
If yes, what type of support is required and when? (e.g. personal care, cooking, cleaning, emotional support).
Describe any formal supports: (e.g. Other providers, ABN support Workers, etc)
*
Please provide information on any Informal supports: (e.g. family, friends, etc)
*
Is the Participant working/studying/volunteering?
*
Yes
No
If Yes, please include place of work/study/volunteering, days and start/finish time that this occurs:
Does the Participant access/use Social & Community Participation?
*
Yes
No
If yes, please include the days/times and support is provided, if any?
Type of individualized living arrangement being considered (select one only)
*
Host arrangement- you live full time with a person or family (host) who is not related to you.
Housemate/Co-residents – you live full time with people who provide care help and companship.
I know a person who can fulfill the role above for me – a potential ILO partner?
*
Yes
No
Has Exploration & Design funding been included in the Participants NDIS Plan
*
Yes
No
Please attach any information/reports/documents relevant to the application (e.g. Functional assessments, behavioural support plans, housing exploration reports, medical reports etc.)
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