4ability - Participant Support Plan
Support Information
Support Plan Start Date
-
Day
-
Month
Year
Date
Support Plan Review Date (Annual)
-
Day
-
Month
Year
Date
Support
Description
How the support will be provided
Participant Details
Name
First Name
Last Name
Date of Birth
-
Day
-
Month
Year
Date
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
Privacy Preferences
Financial Management Arrangements
Participant Contact Information
Current Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Mobile Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
example@example.com
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 Personal Emergency Alarm?
Yes
No
Details of personal emergency device:
GP Details
Name
First Name
Last Name
Practice
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Pharmacist Details
Name
First Name
Last Name
Practice
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Medication
Medication Required - (need Doctor Statment to self administer Medication)
Yes
No
Prompt Required - (need Doctor Statment to self administer Medication)
Yes
No
Assistance Required - (need Doctor Statment to self administer Medication)
Yes
No
Administration Required - (Support Workers are not allowed to Administer Medication. Just registered nurse or medical professional can administer)
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.
Decision Making
Please specify all the people assisting the Participant with decision making
Decision Maker Contact Details
Health and Medical Information
Allergies
Disability, Diagnosis or Medical Conditions
COVID-19 Vaccination Status
Full Vaccination Booster of 3 doses
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
General Practitioner Details
Name
Practice
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Medication Details
Is Medication required?
Yes
No
Is Assistance and Administration required?
Yes
No
Provide details of participant's Medication:
Describe any ongoing health issues the participant has, including mental health issues:
Does the participant have a health or mental health care plan?
Yes
No
Please upload health/mental health care plan
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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
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Does the participant have a signed DNR Order in place?
Yes
No
Please upload signed DNR Order
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Preventative Health Measures
If support is required by the participant, what arrangements are in place to proactively support the participant with preventative health measures, including helping them to access recommended vaccinations, dental check-ups, comprehensive health assessments, and allied health services?
Preventative Health Measures
Where health needs are identified, what is the agreed process that needs to be followed to escalate and respond to medical emergencies?
Disability Supports
Mobility
Needs assistance
Does not need assistance
Is independent
Is not 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
How does the participant prefer to communicate?
Verbally
Non-verbal/vocalise
Sign language
Auslan
Makaton
Key Word Sign
Point/gesture
Augmentative and Alternative Communication (AAC)
Details and Aids used:
Continence
Needs assistance
Does not need assistance
Details and Aids used:
Daily Living Supports
Showering/Bathing
No help required
Aids used
Prompting required
Some support required
Full physical support required
Details:
Grooming
No help required
Aids used
Prompting required
Some support required
Full physical support required
Details:
Dressing
No help required
Aids used
Prompting required
Some support required
Full physical support required
Details:
Toileting
No help required
Aids used
Prompting required
Some support required
Full physical support required
Details:
Eating
No help required
Aids used
Prompting required
Some support required
Full physical support required
Details:
Transfers (mobility)
No help required
Aids used
Prompting required
Some support required
Full physical support required
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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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 a current risk assessment relating to their behaviour or support needs?
Yes
No
Please upload current risk assessment
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Additional Information
Community Participation Supports
Does the participant need assistance getting around the community?
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 NDIS Goals
Type all goals as presented in the participant's NDIS plan
Participant's personal preferences (likes/dislikes)
Goals for support
Supports provided
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: