Shinebright Care Cafe
Day Program, SLES, Work Experience
Participant Name
*
First Name
Last Name
Phone Number
*
Format: (000) 000-0000.
E-mail
example@example.com
Parent/Caregiver Name:
First Name
Last Name
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Please choose from one of the following options:
Day Program
SLES
Work Experience
Do you have a current NDIS plan
Yes
No
Unsure
Dates of Current NDIS Plan
How is your plan managed?
Self-Managed
Plan-Managed
Agency Managed
What ratio do you work best in? (Support worker to participant ratio)
1:1
1:2
1:3
Will you need transport to and from day program?
Yes
No
Please provide in the box below all your NDIS goals
What current strategies do you have in place to assist with emotional regulation?
Do you require any 'assistive technology' or 'visuals' when completing tasks?
Yes
No
Unsure
If you answered 'yes' to the question above, please let us know what 'AT' or visuals are required in the box below.
Do you have any sensory and physical aversions that we need to know about? (ie, water, meat, light, sound)
Yes
No
Unsure
If you answered 'yes' to the question above, please let us know what these aversions are and how you manage these aversions.
Tell me a bit about yourself and what your hobbies are?
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