My Support Care Plan
Support Plan Issue Date:
-
Day
-
Month
Year
Date
Support Plan Review Date (Annual):
-
Day
-
Month
Year
Date
Client Information
Name:
First Name
Last Name
Date of Birth:
-
Day
-
Month
Year
Date
Diagnosis/Disability
Medical Alerts
(E.g Asthma, Dysphagia, Diabetes, Epilepsy, Clozapine)
Allergies
Clozapine
Yes
No
Participant Contact Information
Current Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Mobile Number:
Email Address:
example@example.com
About me
Participant Details
Gender:
Female
Male
Other
Aboriginal or Torres Strait Islander Origin?
No
Yes, Aboriginal
Yes, Torres Strait Islander
Yes, both Aboriginal and Torres Strait Islander
Cultural Background and Preferences:
Preferred Language:
Interpreter Required?
Yes
No
Select any of the following the participant has:
Enduring Power of Attorney (EPOA)
Formal Guardian (OPG, QCAT)
Next of Kin (NOK)
Public Trust
Positive Behaviour Support Plan
Participant's NDIS Goals:
Write current NDIS goals here.
Goal 1:
Goal 2:
Goal 3:
Goal 4:
Goal 5:
General Practicioner Details
Name:
First Name
Last Name
Practice:
Mobile Number:
Email:
example@example.com
Pharmacy Details
Albion Day and Night
Other
Medication
Medication Required:
Yes
No
Prompt Required:
Yes
No
Assistance Required:
Yes
No
Please Give Details:
Support Plans must include clear instructions, agreed with the participant, about what steps staff will take to help the participant with their medication.
Diabetes
Does the participant have a Blood Glucose Monitoring Plan?
Yes
No
BGL Monitoring and Recording Required:
Yes
No
Prompt required:
Yes
No
Assistance required:
Yes
No
Insulin required:
Yes
No
Health and Medical Information
Vaccinations
Full Vaccination Booster of 3 doses of COVID-19
2 doses of a COVID-19 vaccine
1 dose of a COVID-19 vaccine
Has not received a COVID-19 vaccine
Participant is exempt due to medical reasons
Has received a COVID-19 vaccine but unsure on amount of doses
Flu
Pneumonia
Does the participant have any of the following:
Mealtime Management Plan
Asthma Management Plan
Epilepsy Management Plan
Hospital Transfer Form
Resident Profile Contingency
Is the participant currently receiving end of life care/have an End of Life Care Plan?
Yes
No
Please upload End of Life Care Plan
Browse Files
Drag and drop files here
Choose a file
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of
Decision Making
Please specify all the people assisting the Participant with decision making.
Decision Maker Contact Details
Disability Supports
Mobility:
Full assistance
Partial assistance
Prompt to use aids
Is independent
Details and Aids used:
Hearing:
Nil issues
Some issues
Hearing impaired
Details and Aids used:
Vision:
Nil issues
Some issues
Vision impaired
Details and Aids used:
Memory/Cognition:
Nil issues
Some issues
Cognitively impaired
Details and Aids used:
Communication:
Needs assistance
Does not need assistance
Details and Aids used:
Continence:
Needs assistance
Does not need assistance
Details and Aids used:
Daily Living Supports
Showering/Bathing:
Independent
Aids used
Prompt
Partial assistance
Full assistance
Details:
Skin Integrity:
Full assistance
Partial assistance
Prompt
Is independent
Details:
Oral Care:
Full assistance
Partial assistance
Prompt
Is independent
Details:
Laundry:
Full assistance
Partial assistance
Prompt
Is independent
Details:
Grooming:
Independent
Aids used
Prompt
Partial assistance
Full assistance
Details:
Dressing:
Independent
Aids used
Prompt
Partial assistance
Full assistance
Details:
Toileting:
Independent
Aids used
Prompt
Partial assistance
Full assistance
Details:
Eating/Mealtime Management:
Independent
Aids used
Prompt
Partial assistance
Full assistance
Details:
Transfers (mobility):
Independent
Aids used
Prompt
Partial assistance
Full assistance
Details:
Tobacco management:
Independent
Prompt
Partial assistance
Full assistance
Details:
Money management:
Independent
Prompt
Partial assistance
Full assistance
Details:
Day and Night Supports
How often does the participant require supervision or support throughout the day?
None of the time
All of the time
During active times (e.g. getting ready, eating meals, going out, etc.)
Details:
How often does the participant require supervision or support throughout the night?
None of the time
All of the time
During active times (e.g. toileting, transfers, behaviours, etc.)
Details:
Participant's Behaviour Supports
Does the participant have a current Positive Behaviour Support Plan?
Yes
No
Please upload current PBSP
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Choose a file
Cancel
of
Does the participant require a Functional Behaviour Assessment or Restrictive Practice Behaviour Support Plan regarding behaviours of concern?
Yes
No
Does the participant display or engage in any behaviours of concern that require specific support?
Does the participant have any triggers to be mindful of?
Community Participation Supports
Does the participant need assistance getting around the community, including attending appointments and shopping?
What type of transport does the participant mainly use?
Does the participant need assistance to use transport?
Does the participant engage or participate in any recreational, community based, employment or training activities?
Does the participant need assistance to access any of these activities?
Risk Assessment
Refer to your completed participant risk assessment to complete the following section.
Risk Summary
Service Provision
Participant's personal preferences (likes/dislikes):
Emergency Information
Emergency Contact Details:
Does the participant require assistance in an emergency?
Yes
No
Details of emergency support required:
Does the participant have a Medic Alert Device?
Yes
No
Details of Medic Alert Device:
Support Plan Agreement
I, undersigned, agree with the following statements:
I agree that I have been involved in the development of my plan of care, my goals and the services required.
I agree that I have given permission for my Support Plan to be distributed only to the people involved in the development and support of my care including nominated advocates/representatives and may be included in any referrals made on my behalf.
Date
-
Day
-
Month
Year
Date
Participant/Representative Signature
Submit
Should be Empty: