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Comprehensive Care Plan
Use this form to help us plan for your child/Tween support. Make sure to contact us for any updates or changes.
42
Questions
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1
Child/Tween Name
*
This field is required.
First Name
Last Name
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2
Date of Birth
*
This field is required.
of the child please
-
Date
Year
Month
Day
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3
Home Address
*
This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
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4
School name
*
This field is required.
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5
Parent/Guardian
Parent/Guardian Name
Parent/Guardian Mobile Ph:
Parent/Guardian Work Ph:
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6
Culture Background and Preferences
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7
Do you have a Companion /Carer card
*
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YES
NO
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8
Kindly upload the companion /carer card
*
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Max. file size
: 10.6MB
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9
Diagnosis
*
This field is required.
People around me (carers, emergency personnel) need to know that I have the following medical conditions:
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10
Any Anaphylaxis/Allergies
*
This field is required.
People around me (carers, emergency personnel) need to know that I have the following allergies:
YES
NO
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11
Allergy cause
*
This field is required.
People around me (carers, emergency personnel) need to know that I have the following allergies:
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12
Allergy signs & symptoms
*
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ex: rashes, swelling, sweating..
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13
Kindly, upload the Anaphylaxis/Allergy Plan
*
This field is required.
Action plans are only valid for 12months from date of issue.
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: 10.6MB
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14
Any medications
*
This field is required.
Whether given at Home or Wonder Kidz
YES
NO
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15
Medication List
*
This field is required.
Whether given at Home or Wonder Kidz
Medication Name
Home or Wonder kidz and time
Medication Name
Home or Wonder kidz and time
Medication Name
Home or Wonder kidz and time
Medication Name
Home or Wonder kidz and time
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16
Any Dietary requirements
*
This field is required.
I have the following dietary needs (eg. low sodium, lactose intolerant)
YES
NO
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17
Dietary requirements
*
This field is required.
I have the following dietary needs (eg. low sodium, lactose intolerant)
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18
Asthma
*
This field is required.
YES
NO
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19
Please upload Asthma Plan
*
This field is required.
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: 10.6MB
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20
Any other medical conditions
*
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details
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21
Communication
*
This field is required.
The best way to help me understand things is to:
Verbal
None verbal
PECS
AAC
other
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22
Child`s communication
*
This field is required.
The best way to help me understand things is to:
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23
Toileting
*
This field is required.
Independent
needs to be reminded
needs assistance
Pull ups/Nappies
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24
Emergency Contacts
*
This field is required.
Please provide an emergency contact other than the parent/guardian
Emergency Contact Name
Emergency Contact Number
Emergency Contact Relationship to Child/Tween
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25
GP Details
*
This field is required.
Name
Practice
Phone Number
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26
Medicare and Ambulance Information
*
This field is required.
Medicare Card Number
Reference on Card
Card Expiry Date
Ambulance Membership Number
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27
My Therapeutic Support Circle
*
This field is required.
In case of challenging behaviours, my carers need to contact
Speech Therapist
Phone
Occupational therapist
Phone
Psychologist
Phone
Other professionals
Phone
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28
Kindly Upload the latest NDIS goals for your child/Tween
*
This field is required.
the latest NDIS goals
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: 10.6MB
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29
Description Of the Risk
*
This field is required.
towards the child / from the child
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30
Challenging behaviours
*
This field is required.
Ex: wandering, absconding, biting, hitting
YES
NO
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31
Does your child/Tween exhibit any of these behaviours?
*
This field is required.
Should be 1:1 in any of our services for their own safety
Self harm
Harming others
Absconding
Wondering/Eloping
Aggression
Biting
Scratching
Head banging
Escaping
Unbuckle seat belt in the car
Slides under the seat belt in the car
Open locks/doors
property destruction (throwing objects...etc)
extreme sensitivity to sensory input
Severe meltdowns (frequency and duration)
PICA ( eating or chewing on Non-edible objects).
Anxiety and obsession
Refusing to follow instruction
Other
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32
Any Positive Behaviour Support Plan
*
This field is required.
We need to contact the practitioner
YES
NO
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33
Kindly upload it
*
This field is required.
the latest one please
Drag and drop files here
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Max. file size
: 10.6MB
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34
Contacting the behaviour support practitioner
*
This field is required.
We are committed to supporting all our kids and tweens in effectively managing their behaviours and ensuring their well-being. To further assist them, we would like to seek additional strategies from a behaviour practitioner. With your consent, we wish to contact their practitioner to explore a personalised plan to better support them at Wonder Kidz.
YES
NO
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35
Sensory Triggers
*
This field is required.
please list all what applied for your child/Tween (ex: Loud noises, crowded spaces, bright lights, smells)
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36
Interests/Activities to help in Soothing
*
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please list all what applied for your child/Tween(ex: Drawing, Dancing, Lego, Art, Music)
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37
Will Wonder Kidz provide support for my child/tween in home?
*
This field is required.
An in-home risk assessment must be completed prior to the support worker visiting your home. Wonder Kidz will contact you prior to the support date to complete.
YES
NO
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38
What goals would you like our staff to work on with your child/tween at Wonder Kidz?
*
This field is required.
does not have to be therapy goals can be as simple as to eat by themselves...etc
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39
Schedule of support
*
This field is required.
(If unsure of dates or days please answer "as needed")
Program name (eg: Social Saturdays, Afterschool,)
required days
Program name
required days
Program name
Required days
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40
Form filled by
*
This field is required.
First Name
Last Name
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41
Signature
By Signing this care plan, I agree that I have been involved in the development of my childs plan of care, goals and services required.
Clear
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42
Date
*
This field is required.
-
Date
Year
Month
Day
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Should be Empty:
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