Personal Information
Participant Name
Email
example@example.com
Participant Address
Participant/Guardian Phone Number
Please enter a valid phone number.
Date of Birth
-
Month
-
Day
Year
Date
Gender
Cultural or Language Diversities
Next of Kin/ Alternate Contact
Service Request Details
Services Required (click applicable boxes):
Psychology
Occupational Therapy
NDIS Number
Relevent Diagnosis
Plan or Self Managed
Plan
Self
Plan/Self manager Email
Plan Start Date
-
Month
-
Day
Year
Date
Plan End Date
-
Month
-
Day
Year
Date
Service Goals
Support Coordinator Contact Details if applicable:
Further Details:
Risk Assessment
Has the participant ever exercised force, towards any person including a caregiver that caused or could have caused injury?
Yes
No
Does the participant have a diagnosed mental illness (including paranoia)
Yes
No
Is the participant currently taking any mental health related medication?
Yes
No
Does the participant collect/hoard items in their room/house?
Yes
No
If so, do the collected items pose a potential fire risk?
Yes
No
Does the participant smoke?
Yes
No
Does the participant have a history with substance abuse (illicit drugs/alcohol)?
Yes
No
Can the participant effectively communicate their wants and needs to others?
Yes
No
Does the participant currently engage in or have a history ofself-injurious behaviours/self-harm?
Yes
No
Is the behaviour of the participant unpredictable?
Yes
No
Is the participant likely to have access to weapons?
Yes
No
Any Further Details?
Challenging Behaviours
Are their any current or historic challenging behaviours
Type a question
Physical threats/actions
Verbal Physical threats/actions
Unwilling to follow instruction
Absconding
Mouthing/Eating inedibles
Overtly loud or noisy
Impulsive/Agitated
Any Further Details or Challenging behaviours not listed above?
Are there any plans in place to targeting the participants challenging behaviours? Please detail including the persons responsible:
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