Expression of Interest
Please complete this form to express interest in Supported Independent living, Respite, or Community Access support. If you need assistance, contact us at enquires@solidholisticcare.com.au or 1800 716 697
Participant Information
Full Name
*
Preferred Name
Date of Birth
*
-
Month
-
Day
Year
Date
Does the participant identify as
*
Aboriginal
Torres Strait Islander
Both Aboriginal and Torres Strait Islander
Culturally and Linguistically Diverse (CALD)
Prefer not to say
None of the above
Participant Phone Number
Participant Email Address
Participant Address
Does the participant identify with a particular religion or spiritual belief?
Yes
No
Unknown
NDIS Participant Number
*
NDIS Plan Expiry Date
*
-
Month
-
Day
Year
Date
Duration of Current NDIS Plan
*
1 Year
2 Years
3 Years
How is the Participants Plan Managed?
*
Plan Managed
NDIA Managed
Self-Managed
Privately Funded
DCJ Funded
Other
If the participant is Plan Managed, Please provide Company Details. Name & Accounts email.
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Participant Support Needs
What type of support is required
*
Supported Independant Living
Community Access
Respite
Level of Participant Support Needs
*
Standard
Complex Needs
Unsure
High Intensity
Days & Times Support is Required
*
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Diagnosis & Behaviours
Participants Primary Diagnosis
*
Current Behaviours of Concern?
*
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Risk & Safety
Any incidents of physical violence or property damage in the past 12 months?
*
Yes
No
Unknown
Any restrictive practices in place or likely to be needed?
*
Yes
No
Unsure
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Health & other Considerations
Chronic Physical Conditions
*
Diabetes
Asthma
Epilepsy
Chronic Pain
Arthritis (including Rheumatoid Arthritis)
Cardiovascular Disease (e.g., Heart Failure, Arrhythmia)
Chronic Fatigue Syndrome
Obesity
Cancer (e.g., Breast, Lung, Colon)
No, None of the above
Neurological & Cognitive Conditions
*
Dementia
Alzheimer’s Disease
Parkinson’s Disease
Multiple Sclerosis (MS)
Stroke (with residual effects)
Traumatic Brain Injury (TBI)
No, None of the above
Developmental & Intellectual Disabilities
*
Autism Spectrum Disorder (ASD)
Down Syndrome
Intellectual Disability
No, None of the above
Mental Health Conditions
*
Schizophrenia
Bipolar Disorder
Borderline Personality Disorder (BPD)
Depression
Anxiety
PTSD (Post-Traumatic Stress Disorder)
No, None of the above
Other Relevant Conditions
*
Hearing Impairment
Vision Impairment
Sleep Disorders (e.g., Sleep Apnea)
Gastrointestinal Disorders (e.g., Crohn’s Disease, IBS)
Endocrine Disorders (e.g., Thyroid Conditions)
Substance Use Disorders (AOD Concerns)
Known Allergies
No, None of the above
Additional comments
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Goals & Interests
Participant Goals
Interests & Hobbies
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Support Network
Does the Participant have Informal Supports (family, friends, etc.)
*
Yes
No
Does the Participant currently have any formal Supports in place? (services, providers, etc.)
*
Yes
No
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Decision Making
Who makes decisions for the participant?
*
Participant
Guardian
Other
Guardian Name
Guardian Contact Number
Guardian Email Address
Guardian Role/Function
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Participant Documents
Occupational Therapy Report
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Behaviour Support Plan
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Psychiatrist Report
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Speech Pathology Report
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Risk Assessments
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Incident Reports
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Court Orders
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Current NDIS Plan
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Upload any other relevant documents
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Referrer Details
Name
*
First Name
Last Name
Role
*
Company
*
Phone Number
*
Please enter a valid phone number.
How did you hear about SHC
*
Please Select
Facebook
LinkedIn
Word of Mouth
Instagram
Networking Event
Previously worked with SHC
Others
How did you hear about SHC - (complete if you selected others)
Signature
*
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