2. Empowered Support Intake Form

Self Care
Do you require assistance with Personal Care (showering, dressing, grooming)?*
Please provide details about the assistance you require with Personal Care?*
Do you require assistance with toileting and hygiene?*
Please provide details about the assistance you require with toileting and hygiene?*
Do you require support with mobility and transferring (e.g. bed to wheelchair)?*
Please provide details about the support you require with mobility and transferring?*
Do you require help maintaining a clean and safe home (light domestic tasks)?*
Please provide details about the help you require in maintaining a clean and safe home?*

Domestic Assistance
Are you seeking support with household tasks such as cleaning, laundry, or home management?*
Please indicate the types of domestic support you’re looking for:

General house cleaning (e.g. vacuuming, mopping, surfacesLaundry (washing, folding, ironing)Changing bed linenDishwashing or kitchen tidyBathroom or toilet cleaningMeal preparation or light cookingGrocery shopping or household errandsOrganising or decluttering household spacesOther
Other (please specify)

MOBILITY
Please select your level of mobility support required, selecting the description which best fits your current condition.
Mobility Support Requirements?*

LOW - Good to fair mobility (I am able to get up start my day without the use of aids; I can walk short distancesMED - I use mobility aidsMED - Weight affects my mobilityMED - A medical condition affects my mobilityHIGH - High risk of falling or multiple falls in the last 6 monthsHIGH - Full time wheelchair requiredHIGH - Seizures & Tremors
Have you had any falls in the last 6 months?*

ADDITIONAL SUPPORT INFORMATION
Please share a little bit about your passions & interests
Is there anything else in regards to your care needs that we haven’t addressed that you would like to inform us about?

Reminding/Prompting
Do you have a Medication Management Plan?*
Please advise us how you would like us to collect your Medication Management Plan?*

✅ “I can upload my Medication Management Plan now"✅ “I approve for you to request my Medication Management Plan from my Support Coordinator"
Upload: Medication Management Plan

Cancelof
What medications do you take that require reminders, and at what times?*
Do any of your medications have special instructions?*
(e.g., take with food, avoid certain activities)
Do you currently use any system for medication reminders?*
(e.g., pill organiser, family member, verbal reminders, alarms)
Are there any side effects you’ve experienced that we should be aware of?*

Supervision & Recording
Do you have a Medication Management Plan?*
Please advise us how you would like us to collect your Medication Management Plan?*

✅ “I can upload my Medication Management Plan now"✅ “I approve for you to request my Medication Management Plan from my Support Coordinator"
Upload: Medication Management Plan

Cancelof
What medications do you take that require supervision?*
Are there any medications with specific instructions?*
(e.g., take with food, at a certain time of day)
Do you currently have any system for medication reminders?*
(e.g., pill organizer, family member, verbal reminders, alarms)
Have you experienced any side effects that we should be aware of?*
Why is supervision needed?*
(e.g., memory issues, risk of overdose, difficulty swallowing, cognitive impairment)
Do you need full supervision (watching you take the medication) or just a check-in afterward?*
Do any medications have a high risk of overdose or dependency that require closer supervision?*
How do you log your medication records?*

Administering
Administration requires a qualified professional to dispense.

We will further clarify your medication requirements at the next stage.

OUR SUPPORT SERVICES
Which Support Services would you like to explore?

Community AccessNature ImmersionCapacity Building

ANY FURTHER INFORMATION
Is there anything else you would like to share with us in regards to your support delivery that we haven’t already discussed on this form?
Thank you for completing our Empowered Support Intake Form.

Please click SUBMIT to complete the process.
Should be Empty:

Empowered Support Intake Form