Client Care Plan Form
This Ability Support Services Client Care Plan Form
Participant Details
Name
*
First Name
Last Name
Plan Information
NDIS Number
*
Plan Start Date
*
-
Day
-
Month
Year
Date
Plan End Date
*
-
Day
-
Month
Year
Date
Plan Management
*
Plan Managed
Self-Managed
NDIA Managed
Email address if Plan or Self-Managed
example@example.com
Is transport funded?
*
Yes
No
Do you have a companion card?
*
Yes
No
Emergency Contact 1 (if different from guardians)
Name
First Name
Last Name
Phone Number
-
Area Code
Phone Number
Email
example@example.com
Relation to Participant
Emergency Contact 2 (if different from guardians)
Name
First Name
Last Name
Phone Number
-
Area Code
Phone Number
Email
example@example.com
Relation to Participant
Support Coordinator
Do you have a support coordinator?
*
Yes
No
Name
First Name
Last Name
Phone Number
-
Area Code
Phone Number
Email
example@example.com
Back
Next
Needs Assessment
Medication Details
Is medication required?
*
Yes
No
Is Prompting, Assistance or Administration required?
*
Prompting
Assistance
Administation
No assistance required
Provide details of participant's medication (when it is taken, how it is recorded, etc.)
Describe any ongoing health issues the participant has, including mental health issues not already listed
Behaviour Support
Does the Participant have any Behaviours of Concern?
*
Yes
No
Is there a Behavioural Support Plan (BSP) in place?
*
Yes
No
Describe the behaviours of concern that require specific support
Communication
Is assistance required?
*
Yes
No
How does the participant prefer to communicate?
*
Verbally
Simple sentence speech
Non-verbal/vocalise
With Gestures
Sign Language
Auslan
Makaton
Key Word Sign
Communication Device
Details and any aids used
Vision
Aids: Eyecare:
Hearing
Aids: Ear care:
Mobility
Is assistance required?
*
Yes
No
Details and any aids used
Able to walk?
*
Yes
No
Able to run?
*
Yes
No
Able to jump?
*
Yes
No
Able to swim?
*
Yes
No
Toileting and Continence
Type of assistance
*
No help required
Aids used
Prompting required
Some support required
Full support required
Details and Aids used
Showering and Bathing
Type of assistance
*
No help required
Aids used
Prompting required
Some support required
Full support required
Details (including usual times, frequency, level of assistance, and aids used)
Grooming
Type of assistance
*
No help required
Aids used
Prompting required
Some support required
Full support required
Details (including usual times, frequency, level of assistance, and aids used)
Hair care: Nail and foot care: Teeth care: Makeup:
Dressing
Type of assistance
*
No help required
Aids used
Prompting required
Some support required
Full support required
Details
Diet, Nutrition, Allergies
Type of assistance
*
No help required
Aids used
Prompting required
Some support required
Full support required
Details (including usual times, frequency, level of assistance, and aids used)
Goals: Diet/Food Options: Drinking assistance?
Any allergies?
*
Yes
No
Details
Does the participant smoke?
*
Yes
No
Does the participant drink alcohol?
*
Yes
No
Sleepover Support
Does the participant require sleepover support?
*
Yes
No
Details
Sleep Routine: Sleep Aids: Night checks:
Therapies
Are there any regular therapies that the participant attends? Please list.
*
Back
Next
Goals and Interests
NDIS Goals
What are your NDIS goals?
*
Personal Goals
What are some personal goals that you are wanting to work towards?
*
What are some things that you would like to work on at home to build independence?
*
Likes / Dislikes
What are your likes/interests?
*
What are some activities you like to do?
*
Are there any activities you would like to try?
*
What are your dislikes?
*
Are there any religious considerations we should be aware of?
*
Are there any cultural considerations we should be aware of?
*
Submit
Should be Empty: