My Client Journey Workbook

My Intake

INTAKE - Step 1 of 10
This version current at

MonthDayYear
Date
PARTICIPANT DETAILS
Given name/s:
Preferred name:
Family name:
Date of birth:

MonthDayYear
Date
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
Preferred contact method
NDIS Number:
Gender identification
Preferred pronouns
EMERGENCY CONTACT
Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Further comments
CARER / GUARDIAN / DECISION MAKER
Given name/s
Family name
Email address
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Postal address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
In-person contact frequency
SUPPORT COORDINATOR
Name
Name of organisation:
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email address
example@example.com
PLAN MANAGER
Name
Name of organisation:
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email address
example@example.com
REFERRAL DETAILS
Date of referral

MonthDayYear
Date
Are you ?
Select
Reason
Referred by
Contact
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
SUPPORTS / SERVICES REQUESTED
Services / supports
Cultural identification
Specific requirements / preferences (interests, physical/cultural/belief-based requirements):
If modifications to existing facilities or processes may be required, describe here:
Communication preferences
Relies on supports for daily living needs?
Comments
Requires medication management?
Comments
Requires High Intensity Care supports?
Comments

KEY RISK INFORMATION

CRITICAL RISKS — known risks to life, health or wellbeing
Description
Recommended management /response
Do you want to add more?
Description
Recommended management /response
Do you want to add more?
Description
Recommended management /response
KNOWN MEDICAL CONDITIONS OR ALLERGIES
Specify
Effect
Treatment
Do you want to add more?
Specify
Effect
Treatment
INFORMATION SHARING & PRIVACY

Any names added here will be allowed access to this document on request
Sharing information
Provider 1
Provider name
Contact name
Key contact phone
Please enter a valid phone number.Format: (000) 000-0000.
Key contact Email
example@example.com
Frequency of contact
Method of contact
Do you want to add more provider?
Provider 2
Provider name
Contact name
Key contact phone
Please enter a valid phone number.Format: (000) 000-0000.
Key contact Email
example@example.com
Frequency of contact
Method of contact

DISCUSSION CHECKLIST ( For Office Use Only )

Rows	Check	Comment
Right to have a support person present
Right to engage an Advocate
Entry and Exit procedures
Eligibility and priority of access
Conditions that may apply to the service
Privacy and information sharing
Feedback and complaints policy
Rights and responsibilities
Fees

OUTCOME OF INTAKE INTERVIEW
Comment
Reason
Reason
Details
ASSESSMENT INTERVIEW PLANNING
Select
Client's home Address
Other venue Address
Date & Time

MonthDayYear
Date
Hour MinutesAM/PM Option
Attendees
Comment

My Support Planning

SUPPORT PLAN - Step 2 of 10
Date Support Plan Developed

MonthDayYear
Date
Date for Review

MonthDayYear
Date
SUPPORT PLANNING MEETING

( To be filled after plan review or alteration/amendment to plan )

Role

Rows	Name	Comments
Client
Staff member
Health practitioner
Supporters
Advocate
Interpreter
Others

Communication style / mode / tech
Information provided

GOALS - To be filled out by the support coordinator

Rows	CURRENT SITUATION	GOAL	ACTIONS	PERSON RESPONSIBLE	TIMEFRAME	COMPLETED	OUTCOMES
1
2
3
4
5
6
7

NOTES
Things we discussed but didn't include in the plan
Other things…
Feedback about the planning process

What Home Means To Me

HOME - Step 4 of 10
Feelings

To be filled out during client intake - Office Use Only
What makes you laugh, feel happy or excited?
What makes you feel sad or angry?
What activity calms you down? Where is your happy place?
What do you like about your life today?
What are you optimistic about? What do you want in the future?
Things you're pessimistic about…
Things you can do if you feel bored…
Things you can do when you're angry or frustrated…
Activities
What things do you like to do?
Do you like to listen to music? What kind?
Do you have any interests or hobbies?
If you could spend a whole day doing something, what would it be?
What things don't you like to do?
Lifestyle
What things are most important to you?
Are your cultural background or religious beliefs important to you? To your living arrangement?
What do you think about people's habits? (Eating habits, smoking, drinking alcohol, tidiness/messiness, etc.)
What would you like to do but can't now?
What facilities would you like to live close to? (e.g. parks, shops, gym, train station)
Social Network
Who knows you best?
How would they describe you?
How much time do you spend with your family and friends?
What are some things you like about your family and friends?
What personality traits do you share with family members?
How do you decide that you can trust other people?
The person who taught you the most -- what are they like?
How do you feel about spending time alone?
Communicating
What do you wish people would ask you more often?
Are there things you find hard to talk about?
Living arrangements
What comes to mind when you think of a living arrangement?
What do you think about living with children?
What do you think about living with pets?
Support
How can people help you create a living arrangement?
What should people avoid doing when helping?
How do you want your family and friends to be involved in your living arrangement?
What could you do if your living arrangements broke down?

My Risk Assessment Plan

MANAGEMENT - Step 6 of 10
RISK ASSESSMENT DETAILS
Was the participant involved in the assessment?
Select
Reason:
Staff Involved
Others Involved
AUTHORISATION FOR RISK MANAGEMENT PLAN
Authorised by:
Role
Signature
Date

MonthDayYear
Date
Participant / guardian
Date

MonthDayYear
Date
Copy supplied to participant?
Copy placed on participant's file?
Date for Review

MonthDayYear
Date
KEY RISK INFORMATION

CRITICAL RISKS
Description
Recommended management /response
Description
Recommended management /response
Description
Recommended management /response
KNOWN MEDICAL CONDITIONS OR ALLERGIES
Specify
Effect
Treatment
Specify
Effect
Treatment
RELIANCE ON SUPPORTS
Daily living needs
Medication management
High Intensity supports
CURRENT DIGNITY OF RISK DECISIONS

CURRENT DIGNITY OF RISK DECISIONS

Rows	Activity	Possible Risk	Learning goals	Support required	Review frequency/date
1
2
3
4
5

RISK MANAGEMENT PLAN

Participant risks and support-specific risks — including where participants live alone

Rows	Type of Risk	Likely Effect Level(Participant / Others)	Risk Treatment	Person Responsible	Review Date
1
2
3
4
5
6
7
8
9
10

Note

My Health Care Plan

HEALTH - Step 7 of 10
AUTHORISATION FOR HEALTHCARE MANAGEMENT PLAN
Authorised by:
Role
Signature
Date

MonthDayYear
Date
Other people involved in developing the plan
Date for Review

MonthDayYear
Date
Participant / guardian
Date

MonthDayYear
Date
Copy supplied to participant?
Copy placed on participant's file?
HEALTHCARE MANAGEMENT PLAN
Healthcare Management Plan

Medication Management

MEDS - Step 8 of 10
Name
Name
List any Allergies
Allergies or previous adverse drug reactions
Reaction

Attach an allergy management plan if client has severe reactions
Cancelof
Pharmacist Details
Pharmacist Phone Number
Please enter a valid phone number.Format: (00) 0000-0000.
Pharmacist Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Routine Medication

Rows	Name	Dose	Route	Reason for Meds	Start Date	Cease Date / Review Date	Prescriber's Name
1
2
3
4
5
6
7

Special Instructions / Comments

PRN Medications

Rows	Name	Dose	Route	Reason for Meds	Start Date	Cease Date / Review Date	Prescriber's Name
1
2
3
4
5
6
7

Special Instructions / Comments

Short Course Medications

Rows	Name	Dose	Route	Reason for Meds	Start Date	Cease Date / Review Date	Prescriber's Name
1
2
3
4
5
6
7

Special Instructions / Comments

Specialist Medications – eg Insulin, Medicated Patches, Cytotoxic medication

Rows	Name	Dose	Route	Reason for Meds	Start Date	Cease Date / Review Date	Prescriber's Name
1
2
3
4
5
6
7

Special Instructions / Comments
File Upload

Attach diabetes or other specialist management plan.
Cancelof

My Crisis Response Plan

CRISIS - Step 9 of 10
RESPONDING TO MEDICAL EMERGENCIES

RESPONDING TO MEDICAL EMERGENCIES

Rows	Potential Medical Emergency	Symptoms	Level of urgency	Worker response	Monitor	Escalate to	Plan developed by	Review date
1
2
3
4
5
6
7
8
9
10

CLINICAL WASTE SPILLS AND DISPOSAL — EMERGENCY PREVENTION & RESPONSE

EMERGENCY PREVENTION & RESPONSE

Rows	Type of clinical waste	Disposal site	Comment / Protocol
1
2
3

EMERGENCY PREVENTION & RESPONSE

Rows	Spill kit located at:	Disposal site	Comment / Protocol
1
2

Notes:
RESPONDING TO DISASTERS AND CRISES

RESPONDING TO DISASTERS AND CRISES

Rows	Crisis / Effect	Risk Factors	Risk Rating	Crisis Response Plan	Contact	Contact No	Plan in place	Review Date
1
2
3
4
5
6
7
8
9
10

My Support and Risk Reviews

REVIEWS - Step 10 of 10
SUPPORT NAME / RISK TREATMENT / DESCRIPTION: Enter the topic under review — e.g. meal preparation

SUPPORT NAME / RISK TREATMENT / DESCRIPTION:

Rows	Date	WHAT IS WORKING?	WHAT'S NOT WORKING?	GOALS OR SUPPORTS	RISK TREATMENTS	NEW RISKS — add to 'MANAGEMENT'	OTHER CHANGES & COMMENTS
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15

AUTHORISATION
Authorised by:
Role
You agree that you have supplied all documentation that will allow us to commence support including any relevant documentation ie; behaviour plans, meal plans, care-plans, NDIS goals
File Upload

Please upload the missing files here
Cancelof
Signature
Date

MonthDayYear
Date
Copy supplied to participant?
Copy placed on participant's file?
Date for Review

MonthDayYear
Date
Comment
Should be Empty:

Rows	Required / n/a	Comments
Complex Bowel Care
Tracheostomy Management
Ventilator Management
Subcutaneous Injections
Complex Wound Management
Enteral Feeding and Management
Severe dysphagia management
Urinary Catheter Management
In-dwelling Urinary Catheter
In-out Catheter
Suprapubic Catheter
Other(Specify)

Rows	Comment	Tick if help needed
Concentrating
Remembering
Problem solving
Learning new things
What's the best way to learn things?
Understanding conversations
Communicating
Making decisions
Name of person/s required to sign:
Study and training
Other / Notes

Rows	Comment	Tick if help needed
Eating
Sleeping
Washing and dressing
Toilet / bladder / bowel management
Staying alone (e.g. overnight)
Taking medication
Other / Notes

Rows	Comment	Tick if help needed
Standing
Sitting
Using stairs
Moving around in rooms
Public transport
Places I like to go
Places I'd like to go (but feel I can't)
Other / Notes

Rows	Comment	Tick if help needed
Community activities
Shopping
Food preparation
Using phones and computers
Other / Notes

Rows	Comment	Tick if help needed
Meeting people
Making friends
Keeping friendships
Socialising
Family relationships
Other / Notes

Rows	Comment	Tick if help needed
Community groups, clubs etc
Religious groups
Cultural groups
Lifestyle choices
Other:

My Intake

My Support Planning

My Strengths and Needs

What Home Means To Me

My Risk Assessment

My Risk Assessment Plan

My Health Care Plan

Medication Management

My Crisis Response Plan

My Support and Risk Reviews