Support Plan Review Request
Please complete this form to help us understand your current care needs that support the reassessment request
Members full name
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First Name
Last Name
Date of Birth
*
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Day
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Month
Year
Date
Your email address
example@example.com
1. Please describe any change in circumstances that has led to your need for a higher level of care.
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Hospital discharge
Change in cognitive status
Change in care needs or medical condition
Change in caring arrangements
Change in living arrangements
Needs residential respite
Recent falls or risk of falling
Describe how the above has impacted your needs
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What supports are you currently accessing?
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Everyday Living (General cleaning, light gardening, meal prep, shopping assistance)
Independance Supports (Personal care, transport, social support and community engagement)
Clinical (Allied Health services ie Podiatry, Physiotherapy, ect.)
Assistive Technology / Home Modifications Scheme (AT/HM)
Restorative Care Pathway
End of Life Pathway
3. What additional services do you need support with?
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Everyday Living (General cleaning, light gardening, meal prep, shopping assistance)
Independance Supports (Personal care, transport, social support and community engagement)
Clinical (Allied Health services ie Podiatry, Physiotherapy, ect.)
Assistive Technology / Home Modifications Scheme (AT/HM)
Restorative Care Pathway
End of Life Pathway
4. Are you currently receiving any other formal or informal support services?
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Commonwealth Home Support Program (CHSP)
Volunteer or community services
Informal care arrangements (Friend or family)
Other funded services (Eg: Podiatry via Medicare)
Other
If other, please provide us more information
5. A Support Plan may take some time, what alternative option have you considered to help support you for the time being?
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CHSP funding codes accessed
Family or friends are supporting me
Im accessing respite care (residential, carer gateway ect.)
Im utilising all unspent funds
Paying for services privately
Other
If other, please provide us more information
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6. To be eligible for a reassessment, the below must apply. Please confirm that your funding is being maximised for ongoing services, and your unspent funds is unable to support your care needs for the next 3 months.
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I confirm
The above do not apply
To support your application, please attach any relevant documentation (e.g., GP health summary, OT/physio reports, specialist letters).
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