Alora - Client Information and Authority Form-2001

CLIENT INFORMATION AND AUTHORITY (Form-2001)
Personal information
Name

First Name Last Name
Preferred Name
Date of Birth

Day Month Year
Date
Phone
Address

Street Address

Street Address Line 2

Suburb State

Post Code
Primary Disability
Secondary Disability
Medicare Number
Private Health Fund
Membership Number
Arrival Date

Day Month Year
Date
Departure Date

Day Month Year
Date
Length of Stay
Likes/Dislikes
Hobbies
Next of Kin/Emergency Contact
Name

First Name Last Name
Contact Phone
Relationship
Other Contacts Name

First Name Last Name
Phone Number
Referring Agency
Referring Agency and Name
Email
example@example.com
Phone
Current Situation
What is the need for Short Term Accommodation?
NDIS
Do you have an NDIS plan?

Yes No
Plan start date:

Day Month Year
Date
Plan end date:

Day Month Year
Date
NDIS Number
Agency Managed Self-Managed Plan Managed (if yes, please provide Plan Manager's details)
Plan Manager's Name

First Name Last Name
Email
example@example.com
Phone
Do you have an NDIS Coordinator?

Yes No
Has your Support Coordinator been informed of your stay with us?

Yes No
Support Coordinator Name

First Name Last Name
Company
Phone
Transportation
Do you have transportation included in your NDIS plan?

Yes No
Agency Managed Self-Managed Plan Managed
Do you have a companion card?

Yes No
Do you have a taxi subsidy card?

Yes No
Do you have a Translink Access card?

Yes No
Medical Contacts
General Practitioner
Address

Street Address

Street Address Line 2

Suburb State

Post Code
Phone Number
Treating Hospital
Phone Number
Medical Information

General Medical Information

	Yes	No	Comments
Diabetic
Asthma
Anaphylaxis
Epilepsy
Heart Condition
Any other concerns not listed?

Behaviours, Concerns and Triggers
Are there any behaviours of concern, triggers or things to be mindful of?
Do you have a Positive Behaviour Support Plan?

Yes, attached No
Please attach Positive Behaviour Support Plan here

Cancel of
Do you have any other supporting evidence? E.g. Functional Capacity Assessment, psychological assessment, hospital discharge summaries or any other type pf allied health assessment?

Yes, listed below and attached. No
Please attach relevant assessment here

Cancel of
Additional documents
File Upload

Cancel of
Medication
Do you currently take any prescribed medication?

Yes, medication chart attached. No
Allergies
Please list any allergies you have including material/drug and how the adverse reaction presents. Please also list the response and management strategies.
Request for Medical Assistance
I hereby request management/staff of Alora Retreat to assist me with my medication as prescribed by my medical practitioner.
I also understand that:
- In accordance with Section 8 of the Residential Services (Accreditation) Regulation 2018,Alora Retreat will follow the recommended principals of the seven ‘rights’ for safe medication administration that have been developed within the healthcare sector and are widely used. They are:
  
  1. Right person
  
  2. Right medication
  
  3. Right dosage
  
  4. Right time
  
  5. Right route
  
  6. Right to refuse
  
  7. Right documentation
- this means assisting me to access appropriate non-prescription medication in accordance with the directions provided by the manufacturer.
- this means assisting me with alternate medications recommended by my medical practitioner and/or pharmacist.
- Alora Retreat is authorised to store such medication safely in a locked area within the facility.
- my prescriptions can be given to the pharmacist as required.
- if I am not present at the agreed time and location to receive assistance with medication, management/staff are authorised to make all reasonable efforts to locate me. Third parties Alora Retreat may contact include family, friends, government agencies and emergency services. If unfound, Alora Retreat may report to the appropriate people, clinics and/or medical practitioners immediately.
- should I miss a dose for any unplanned reason, or if I refuse to take the prescribed medication, I do so at my own risk, and that staff can notify my medical practitioner.
Participant's Name

First Name Last Name
Signature

Clear
Date

Day Month Year
Date
Signature of Authorised person (substitute decision maker)

Clear
Date

Day Month Year
Date
Relationship/status
Consent to be Photographed
During your stay with us, Alora Retreat may be taking photographs or video footage to use in promotons that may include, but not limited to, materials such as brochures, newsletters, websites and social media. Do you give us permission to use photographs, images and/or video taken of you in such promotions?
Please tick:

Yes No
I acknowledge that copies or photographs and video footage involving me can be obtained from Alora Retreat by making a written request.
Authority to Share Information
I, the undersigned, do hereby grant permission to Alora Retreat to collect and disclose information which is relevant to the support services provided. I understand throughout the provision of my regular and ongoing support, Alora Retreat will use this consent as authority to collect and disclose my information to/from relevant third parties and agencies required to provide these support services.

Alora Retreat may disclose my personal information to:
- Alora Retreat related entities to facilitate internal business processes
- Commonwealth and State departments and agencies which provide funding for services (i.e. NDIS Auditing purposes, Office of Public Guardian, Public Trust, NDIA)
- Contractors and/or agencies who provide on behalf of Alora Retreat
- Your NDIS registered Support Coordinator and/or your Plan Manager
- Other NDIS service providers who offer supports (i.e. Centacare, Endeavour)
- Health and allied health professionals who provide specialist support to facilitate the delivery or support services (i.e. GP, physiotherapist, hospitals)
- Third parties including Queensland Police Service, to help with identification in the case of missing persons, and
- Emergency medical and ancillary staff in an emergency.
I understand that it is my right to choose if specific organisations are excluded from accessing or receiving information Alora Retreat holds about me. Therefore, by indicating in writing below, I DO NOT give authority to Alora Retreat to contact or disclose my information to the following:
Participant's Name

First Name Last Name
Signature

Clear
Date

Day Month Year
Date
Witnesses by

First Name Last Name
Date

Day Month Year
Date
Criminal History Declaration
Criminal History:

Yes No
If YES, please provide info:
Risk Assessment
Do you have a risk assessment from another service provider/health facility? Please attach.

Yes No
FOR OFFICE USE ONLY
Assessors Name

First Name Last Name
Date of Arrival

Day Month Year
Date
Date of Departure

Day Month Year
Date
Should be Empty:

CLIENT INFORMATION AND AUTHORITY (Form-2001)

Personal information

Next of Kin/Emergency Contact

Referring Agency

Current Situation

NDIS

Transportation

Medical Contacts

Medical Information

Behaviours, Concerns and Triggers

Medication

Allergies

Request for Medical Assistance

Consent to be Photographed

Authority to Share Information

Criminal History Declaration

Risk Assessment

FOR OFFICE USE ONLY