Service Request Pirates Service

Service Request Pirates Service
About Pirates's Services

Pirates is the QLD trading name for Wonderland Community Services Pty Ltd is a registered NDIS Provider: 4050042146

Wonderland is committed to a holistic service for our participants meaning we want to improve the whole experience of our participants in their life working with family, friends and other network supports.

We have two main divisions - our Accommodation and Care Services and our Professional Services. Our staff work seamlessly accross these services if required. (www.piratesrest.com.au)

In our accommodation and care services we always look to build the capacity of our participants and in our professional services we always consider the reality of the day to day practical needs of our participants.

* Pirates Rest - Short Term Supported Accommodation and Respite - QLD 1-14 days.

* Pirates Haven - Medium Term Accommodation - QLD 2 - 12 weeks.

* Pirates Care - In-home support

* Pirates Adventures - Social, community and recreation activities - out and about.

Learn more about these great new creative initiatives on our Pirates Rest website.

Let us know if we meet your expectations! We hope we do and exceed them as well.

Toni Mehigan - Director
Choose your service
NDIS Service Request

0115 Short Term Accommodation - Pirates Rest0104 Supported Independent Living - Pirates Haven0115 Medium Term Accommodation - Pirates Haven0107 Daily Personal Activities - Pirates Care0125 Social, Community & Recreation Activities - Pirates Adventures
Demographic Information
Referral Date*

DayMonthYear
Date
Who is filling in this form?
Participant Name*

First NameLast Name
Date of Birth*

DayMonthYear
Date
NDIS Number*
Current NDIS Plan

Browse Files

Cancelof
Guardianship
Guardianship Type
Guardian Name
Guardian Phone
Guardian Email
example@example.com
Participant Address
Participant Phone (if appropriate)

Area CodePhone Number
Participant Email (if appropriate)
example@example.com
Coordinator of Support (COS) Name

First NameLast Name
COS Phone

Area CodePhone Number
COS Email
example@example.com
COS Organisation
COS Organisation Address

Street Address

Street Address Line 2

CityState

Post Code
Current Additional Service Providers
KEY CONTACTS
You may like to include family and other medical or professional contacts in the below table. This may include the GP or Out of Hours GP, family contacts, Speech or Occupational Therapists etc.

Key Contacts

	Profession/ or family member	Name	Phone	Email
1
2
3
4
5
6

CARE PLANNING INFORMATION
About the participant
Diagnosis

AutismIntellectual ImpairmentAcquired Brain InjuryPsycho/Social DisabilityOther Physical DisabilityGenetic ConditionOther
Medical Condition

ADHDMental HealthDiabetesEpilepsyAllergiesMeal Management requirementsOther
How can we help?

Relationship strengthening (making friends)Social and community connectionsHoliday or mini-breakGreater independenceBuilding life skillsEstablishing routinesSafety in day to day activitiesExtending interestsMore interaction with natural environmentImproved physical healthSupport for hyperactivityPreparation for workWork opportunitiesBreak from current living arrangementsImproved emotional healthEmotional self-managementBehaviour supportSupport for sexualised behavioursLessen dependence on social media and gamingSupport for homelessness (between houses)Other
Further Diagnostic Information
What is the participant's current COVID-19 vaccination status?

Fully VaccinatedDose oneBoosterOther
Please attached a copy of the participant's COVID-19 vaccination certificate.

Browse Files

Cancelof
Current Medications
Please outline what each medication is for.
Are the medications listed used for a diagnosed physical disability? (ADHD & Autism are considered neurodevelopmental physical disorders.)*

YESNO
Are the medications listed used for Chemical Restraint?*

YESNO
Most Recent Doctor's Orders

Browse Files
Send these later if you don't have them now Cancelof
Professional Reports including Medical Plans or Meal Management Plans

Browse Files
Please provide any existing professional reports you can send this later if you don't have them now Cancelof
Existing Services with our Organisation

0110 Behaviour Support0128 Therapeutic Support0118 Early Childhood Intervention0132 Specialist Coordination of Support0115 Short Term Accommodation0115 Medium Term Accommodation0107 Daily Personal Activities0125 Social, Community & Recreation Activities
Does the participant have any of the following?

A current Behaviour Support Plan with no restrictive practicesA Behaviour Support Plan with restrictive practicesWe are waiting for a behaviour support specialist
If you have a Behaviour Support Practitioner please put their name and contact details below.
Tell us what else we are doing for you currently or what we have done for you in the past.
Participants Main Goals
Participants Particular Health & Support Needs
Participants Interests, values & beliefs
Please provide as much information as possible so that we can support these areas well.
SAFETY ISSUES
Age Range for Participant
PLEASE NOTE (for duty of care for very young participants)

Under 8 yrs participants will automatically be placed on a 1:1 support ratio.

Under 12 years participants will automatically be placed on a 1:2 support ratio or higher depending on safety requirements.
The following assessment has been designed to ensure safety for participants while participating in off site activities and in day to day living experiences while in our care.

Please rate the level of need for this participant.

1 - little support (requiring 1 worker to 4 participants - 1:4)

2 - low support (requiring 1 worker to 3 particpants - 1:3)

3 - moderate support (requiring 1 worker to 2 participants- 1:2)

4-high support required (1:1 support)

5 - extremely high needs (2:1 support)

DAILY LIVING

	Support Rating (1-5)	Comments
Toileting
Showering
Medication support
Sleep/waking
Eating
Vehicle Support
Privacy/need for own room
Dressing
Mobililty
Health Issues

COMMUNICATION

	Support Rating (1-5)	Comments
Speech language impairment
Prefers not to speak
Non-verbal
Uses communication aids/devices
Non English Speaking background
Hearing impairment
Low literacy/numeracy capacity
Relational communication
Communicating basic needs
Swearing/profanities

RECREATIONAL ACTIVITIES

	Support Rating (1-5)	Comments
Swimming
Horse Riding
Walking/stamina
Climbing/hiking
Stairs
Exertion
Balance
Noise
Group activities
Technology Issues
Movie Ratings

BEHAVIOURS

	Support Rating (1-5)	Comments
Interaction with others
Team competition interactions
Crowds
Noise
Wandering
Running away
Propensity to violence/aggression
Propensity to react to others
Attention seeking
Stealing
Confabulation - stretching the truth
Oppositional
Sensory Sensitivity (overload)
Sensory Seeking (hyperactive)
Self harm
Time out - needs space
Sexualised behaviours
Smoking
Issues with illegal drugs
Depression
Anxiety
Other mental health needs
Suicidal ideation or behaviours
Drinking alchol

MEDICAL

	Support Rating (1-5)	Comments
Epilepsy
Shunts
Nose bleeds
PTSD
Mobility
Special feeding devices
Incontinence
Asthma
Allergies
High Risk issues/illnesses or diseases

VISITING PARTICIPANTS PROPERTY

	Comments
Dogs
Neighbours to watch out for
Trip hazards
Remoteness
Other dangers for staff

Other Important Information we should know?
Referrer's Email*
example@example.com
Role/ Relationship to Participant*
Signature
Date

DayMonthYear
Date
Version date 17.09.2021
Should be Empty:

Service Request Pirates Service

Demographic Information

KEY CONTACTS

CARE PLANNING INFORMATION

SAFETY ISSUES