Request for Home and Living Supports

Home and living supports can assist you to live independently, and improve your living, household and management, social, communication, and behavioural management skills.

For more information on the types of Home and Living Supports you may be available to request, please view the following NDIS website: https://www.ndis.gov.au/participants/home-and-living

Who can complete this form?
Participants or a person acting on their behalf, such as a family member, friend, stakeholder or guardian. In this form we use the term ‘You’ and ‘Your’. This is referring to the NDIS participant.

You can fill out this form electronically or print and complete it using a blue or black pen.

Full name*

PrefixFirst NameMiddle NameLast Name

Date of Birth*

Date

NDIS Number*

Current Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Email*

example@example.com

What is your main reason for this request? Mark 'Yes' for only the reasons that apply to you.

	Only mark if 'Yes'
I want to live more independently.
I want to move out of home for the first time.
I want to move closer to my family/friends/work/school.
The health or age of my primary carer.
I don't have enough informal supports.
I am experiencing/ have experienced family/domestic violence.
I am experiencing/have experienced family or relationship breakdown.
Community housing.
My current housing arrangement is overcrowded.
I am not able to live with my immediate family.
My current lease has ended or is ending soon.
I received an eviction notice.
I have received a warrant of possession.
I have received a notice of termination/my tenancy is at risk.
I can't pay my rent/ my rent is unaffordable.
I am a homeowner and I am experiencing mortgage stress.
My current property is substandard.
My current property is dangerous/in need of repairs.
Design restricts daily living activities - such as bathing or mobility.
My current living arrangement aggravates my disability/medical condition.
I currently live in a residential aged care facility and would like to move out.
I am leaving hospital.
I am leaving care/child protection.
I am leaving a custodial setting.

Is there another reason for your request?*

No. Move to the next question.Yes. Please briefly describe it below.

Reason

What is your current living arrangement? Mark 'Yes' for only the arrangement that best describes your situation in the table.

	Only mark if 'Yes'
Private home: owned by self/ family/ friends.
Private home: rented from private landlord.
Private home: rented from public authority.
Public housing
Community housing
Specialist Disability Accommodation (SDA) housing
Aboriginal Community Housing
Group home/ SIL provider home
Large residential (more than 20 people)
Small residential (less than 20 people)
Temporary/crisis accommodation
Couch surfing
Community services placement/foster care
Voluntary Out of Home Care (VOOHC)
Caravan
No dwelling/ street/ park/ in the open
Motor vehicle
Boarding/rooming house
Emergency accommodation
Hotel/ motel/ bed and breakfast
Hospital (excluding psychiatric)
Psychiatric hospital/unit
Disability support Rehabilitation
Adult correctional facility (jail/gaol)
Youth/juvenile justice correctional centre (jail/gaol)
Boarding school/ residential college
Aged care facility

Do you have a different living arrangement that is not listed above?*

No. Move to the next question.Yes. Please briefly describe it below.

Describe briefly:

4.1 Do you have a housing and living support goal in your NDIS plan?*

Yes. Move to Part 5.No. Please write what your goal is below.

4.2 Do you want to add this goal or another housing and living goal to your plan at plan review?

Yes, I want to add the goal I listed in question 4.1 above.Yes, I want to add a different goal to what I listed in question 4.1 above.No, I do not want to add any new goals.

What housing and living supports will best help you to meet your goals? Mark 'Yes' only for the supports that you need.

	Only mark if 'Yes'
Help with maintaining my current home environment.
Help with designing and developing my housing and living supports.
Help to find other people to live with.
Help modifying my current home.
Help with personal care/daily life tasks at home.
Access to assistive technology and equipment.
Help to find a different home.

6.1 Who do you currently live with?*

6.2 How long have you lived in your current arrangement?*

6.3 Where did you live before your current arrangement?*

Please tell us the address, type of home and living situation it was.

6.4 How are you managing at home now?*

Is there anything that is unsafe or impacting your daily activities at your current home?

6.5 What is the most important to you for your future living arrangements and support needs?*

For example, this may be to have a safe and stable home or be closer to friends and family, to have space for your children to visit, to be more independent or to have an accessible home.

6.6 Do you have any cultural, religious, lifestyle or personal preferences? If not, move on to the next question. If yes, please tell us below.*

6.7 How would a change to your current living arrangement or supports, improve your overall wellbeing or functioning?*

6.8 Do you receive assistance right now from a carer or support person?*

YesNo

6.8.1 Please tell us their details and what they do for you below:*


Name of carer or support person
Contact phone number
What support do they provide for you?

6.9 Is there anything else you would like to tell us about your current housing and living situation?*

YesNo

6.9.1 Please tell us below:*

How do you manage everyday tasks? Please tell us your ability with the tasks listed below. Mark only one for each task listed.*

	Can do	With help	Cannot do
Housework
Transport
Shopping
Cooking/meal preparation
Managing money
Using a phone
Home/lawn maintenance
Walking
Climbing stairs
Transfers
Bed mobility
Carrying/moving items
Accessing the community
Washing yourself
Using the toilet
Dressing yourself
Eating
Drinking
Communicating
Taking your medication
Fire safety
Personal safety
House safety
Following a routine
Making friends/ relationships
Maintaining boundaries
Managing my own behaviour

Do you need support with your health care needs? Please tell us by selecting 'Yes' only for the health care need(s) that apply to you.

	Only mark if 'Yes'
Complex bowel care needs
Intermittent catheterisation
Wound care support
Ventilator dependent
Epilepsy
Percutaneous endoscopic gastrostomy (PEG) tube feeding
Diabetic management
Nasogastric tube feeding
Tracheostomy
Post seizure PRN for unstable seizure activity
Non-invasive Positive-Pressure Ventilation (NPPV)
Bilevel Positive Airway Pressure (BiPAP) ventilation
Constant Positive Airway Pressure (CPAP) ventilation

9.1 Have you completed or had a review of any of the plans or programs listed below in the last 12 months? Select 'Yes' only for those that apply to you.

	Only mark if 'Yes'
Behaviour support plan
Restrictive practice authorisation
Police protocol
Mealtime management plan
Nutrition and swallowing checklist
Health care plan
Hospital management plan
Risk assessment
Manual handling plan
Communication plan
Seizure management plan
Toileting program

9.2 Have you completed or had a review of a plan or program that was not listed above?*

YesNo

9.2.1 Please tell us below:

10.1 Do you currently use assistive technology or equipment?*

YesNo

10.1.1 Please tell us what it is below:

10.2 Have you had any home modifications done in the past?*

YesNo

10.2.1 Please tell us what they were below:

11.1 Do you receive any help with decision-making?*

YesNo

11.1.1 Please tell us who helps you below:

	Details
Full Name
Contact Phone Number

11.1.2 What is your relationship with this person? Please mark the relevant box below:*

They are my NDIS nominee.They are my legally appointed decision maker (please provide us with details of this appointment if you have not already).Other. Please tell us what your relationship with this person is below.

11.2 Did you receive any help with completing this form?*

Yes, it was the person listed in question 11.1.1 above.Yes, but it is a different person to the person listed in question 11.1.1 above.No.

11.2.1 Please tell us who has helped you below:*

	Details
Full Name
Contact Phone Number

11.2.2 What is your relationship with this person?*

They are my NDIS nominee.They are my legally appointed decision maker (please provide us with details of this appointment if you have not already).Other. Please tell us what your relationship with this person is below.

12.1 What information, if any, do you give consent to share with this person? Please mark the relevant boxes below:*

A copy of all parts of my current NDIS plan.A copy of my current NDIS plan's goals and aspirations.A copy of my current NDIS plan's funding and support.Nil/not applicable.Other. Please specify below:

12.2 What actions, if any, do you give consent for this person to do on your behalf?*

To request review of your plan, including due to change in circumstances.To request a review of a decision made by the NDIA.To make arrangements for a scheduled plan review.To assist with the submission and implementation of requests for Assistive Technology, Home Modifications or other specific supports.To manage a complaint made by you.Nil/not applicable.Other. Please specify below:

12.3 What is the reason, if any, you are providing this person with consent?*

To complete and sign this Request for Housing and Living Supports.Nil/not applicable.Other. Please specify below:

12.4 Is there any other information you consent to share with this person?*

No.Yes. Please specify what this information is below:

12.5 What length of time, if any, are you providing the consent for?*

Please indicate how this form has been completed:*

I (the participant) have been directly involved in this Housing and Living Supports Request and the information recorded in this form reflects my wishes.As the participant's delegate, I have sought at all times for the participant's input, decision-making and preferences to be at the centre of this Housing and Living Supports Request. I endorse the information in this form.

13.1 Participant acknowledgement

Please note: NDIS participants have other options instead of signing here. If you are unable to sign here, you can direct someone aged 18 and over to sign, in the section below called ‘Delegate acknowledgement’. Someone else can also sign the ‘Delegate acknowledgement’ if you have provided consent for them to act on your behalf in part 12 above.

Participant's full name*

First NameLast Name

Participant's signature*

Date*

Date

13.2 Delegate acknowledgement.

Please note: Please note: This section is only to be completed if the participant is unable to sign above. Instead, their chosen delegate must be aged 18 and over and can sign below.

Delegate's full name*

First NameLast Name

Delegate's signature*

Date*

Date

13.2.1 What is your relationship with this person? Please mark the relevant box below:*

I am their NDIS nominee.I am their legally appointed decision maker (please provide us with details of this appointment if you have not already).Other. Please tell us what your relationship to the participant is below.

Request for Home and Living Supports

1. Participant Details

2. Reason for this request

3. Current Living Arrangement

4. Housing and Living Support Goals

5. Support to Help You

6. Your Current Housing and Living Situation

7. How You Manage Tasks

8. Your Health-care Needs

9. Assessments and Reports

10. Assistive Technology and Home Modifications

11. Your Decision-making

12. Participant Consent

13. Acknowledgement