• Participant Referral Support Plan

    Personal Information & Emergency Contact - Step 1 of 6

  • Support Plan
    This support plan will include important personal and safety-related information about the participant and the working environment.

    The support plan will be made available to your support worker or team of support workers. Please include as much details in the support plan as possible so that the workers will be prepared to provide you with the best possible support.

    This plan will consist of:
    1. Personal information
    2. Health and Medical
    3. Safety Assessment Personal

  • Date of Birth
     - -
  •  -
  • Language
  • Language
  • Interpreter Required
  •  -
  • NDIS Plan Start Date*
     - -
  • NDIS Plan End Date*
     - -
  • Does the Participant live alone
  • Is the participant supported by only one worker
  •  -
  •  - -
  •  - -

  • Participant Referral Support Plan

    Health and Medical Information - Step 2 of 6
  • Is the client at risk of choking, seizures or anaphylaxis
  • Is assist with medication administration required
  • Does Client suffer from irritants, phobias or any other specific condition.
  • Do you give consent to share this form with your support network, other providers, and relevant government agencies?

  • Participant Referral Support Plan

    Goals - Step 3 of 6

  • Participant Referral Support Plan

    Home Safety Assessment - Step 4 of 6
  • Is this home easy to locate
  • Is onsite/street parking available for support worker’s car
  • Are any gates or doorways difficult to use or access
  • At night, is the house entrance hard to find
  • Are there any slip, trip or falling hazards outside the home
  • Is the home wheelchair accessible
  • Are there any slip, trip or falling hazards inside the home
  • Will the support worker be required to use any electric appliances
  • Are there any pets, assistance animals or other animals located at the home
  • Upon request, can the pets, assistance animals or other animals (as applicable) be kept in a securearea, away from areas where the support worker will be working and unable to reach the supportworker

  • NOTE:

    It is the participant’s responsibility to ensure certain safety requirements.

    1. Electrical appliances and power cords are in good working order.
    2. Power cords are attached to power boards and power sockets, and not double adapters.
    3. The house is fitted with a working smoke alarm.
    4. The fuse box is fitted with a safety switch.
    5. Support workers will not be exposed to cigarette smoke in the home

  • Participant Referral Support Plan

    Community Participation - Step 5 of 6
  • Is there a risk that participant may abscond

  • Participant Referral Support Plan

    Transport - Step 6 of 6
  • What type of transport participant will use? Please tick the relevant.
  • Do you give consent for the support worker to proactively support you in attending medical, and allied health services?

  • KoalaKare will take reasonable efforts to work with the participant in selecting the preferred support worker

  • Date / Time
     - -
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