Wheelnutz Garage Intake Form

Representative or Emergency Contact Email address

example@example.com

NDIS plan number

NDIS funding category

NDIS funding type:

If not NDIS funded, what funding arrangement is in place? Tell us below:

If self or plan managed, what email do we sent invoices:

example@example.com

NDIS Goals - write your goals below. If not NDIS related, what do you want to achieve at Wheelnutz Garage?

NDIS plan start date:

Date

NDIS plan end date:

Date

DISABILITY: What is your disability? Both Primary and Secondary and anything else you'd like to include.

ALLIED HEALTH REPORTS - it's really useful for us to have a copy of your Allied Health Reports. It means we can change and tailor tasks, and we can compliment what your therapy is working on. Which reports are you happy to send us:

Please upload Allied Health reports here:

QUESTION 1 (Mental health) ******WATCH THE VIDEO BELOW before answering ***** Understanding how your mental health and wellbeing impact you daily, will help our staff to better understand how to support you each time you're in the garage. Knowing that you often suffer depression, anxiety or other mental health conditions is very useful. Write below what mental health challenges you have, how regularly this might happen, and when you are struggling in the garage, how can we support you best?

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QUESTION 2 (Physical health) *** WATCH THE VIDEO BELOW before answering**** Knowing whether you have any health issues like diabetes, epilespy or asthma will help us to respond if you need support in the garage. If you also have these health issues WE WILL NEED A COPY OF YOUR MANAGEMENT PLAN. List below all your health issues including any medications that might impact your time in the garage, and how we can help you at Wheelnutz?

Please upload your MANAGEMENT PLAN here (Diabetes, Epilepsy, Asthma)

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QUESTION 3 (DIETARY NEEDS) - Whilst you bring your own lunch and snacks, occasionally we might provide food such as birthday cake. Tell us below if you are vegatarian or vegan, if you have any dietary requirements, or have any allergies?

Please upload your DIETARY PLAN here (allergies, anaphylaxis)

QUESTION 4 (Getting around the garage/ Gross motor skills) *** WATCH THE VIDEO BELOW before answering ****. Thinking about a garage environment, there is lots of equipment around but don't let that stop you from getting involved. But we do want to know about what assistance you might need - how steady are you on your feet, do you need to sit down regularly, do you have any walking aides, do you have a history of falls, do you need assistance getting out of the car? Tell us below about your gross motor skills (walking, jumping, balancing, coordinating)

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QUESTION 5 (Working with your hands/ Fine motor Skills) *** WATCH THE VIDEO BELOW before answering *** We want you to thrive, grow in confidence and be independent in the garage whilst also working with a team. You will always be supervised by staff, but we don't want to interfere if you are mastering a new task like screwing in a bolt Tell us about both your fine motor skills (using your hands and fingers)

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QUESTION 6 (Working with your team) *** WATCH THE VIDEO BELOW before answering **** You will be part of a team, people you won't know at first. Some of them will become friends, others you won't really like but you still need to find a way to work with them. Tell us about how you will go working with others, and how a garage environment might impact this. (Garage is often loud, smelly, hot, lots of activity and energy) This is where you can share some things about communication needs, your sensory challenges, your emotional regulation strategies, your need for personal space, maybe you can't keep your hands to yourself. Tell us below:

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QUESTION 7 (BEHAVIOURS) *** WATCH THE VIDEO BELOW before answering **** Knowing how to support you to get the most out of your involvement is necessary. Information about memory or concentration challenges, decision making processes, particular behaviours your therapists might be working on with you, are all very helpful. Tell us below:

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QUESTION 8 (Connection, belonging and making friends) ***WATCH THE VIDEO BELOW before answering *** We don't just build cars in the garage, we make friends, we share stories and we create memories together. It would be really useful to know things about you such as your favourite food, do you like music, what do you do on the others you're not at Wheelnutz, hobbies, sports or employment? Its helpful to identify others that shares your interests and introduce you during your first week. Tell us below:

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Is there anything else you want to share that will make your experience a positive one? (you will need to put an answer in the box, even if its 'NO')

Thank you for your interest in Wheelnutz Garage.

The next steps will include:

1. Our Admin team will be in touch to discuss your preferred sessions, garage location, NDIS details and funding category.

2. Our Admin team will then email your Service Agreement and Schedule of Support.

3. Once these documents have been returned, your first session will be scheduled and an email confirmation sent.

4. We encourage you to go to our YOUTUBE CHANNEL and look at the short videos to become familiar with your chosen garage.

5. If you are being transported by a Support Worker, we also ask that you watch our YOUTUBE video called 'PROGRAM GUIDELINES FOR SUPPORT WORKERS'.

6. Start preparing for your first session ensuring you have a pair of steel cap/safety toe boots/shoes, a heavy duty water bottle, preferably dark clothes that you can get dirty, snacks and lunches to bring.

SUPPORT PLAN: Participant Introduction (staff notes)

SUPPORT PLAN: In the garage assistance including reasons for being here (staff notes)

SUPPORT PLAN: Significant support needs, health management plans or Positive Behaviour Support Plan available

Date

Consent - Please sign below to indicate your consent and agreement to the details set out in this Participant Intake form above

If this Intake Form is being completed on behalf of the participant, please provide your first name and last name in the section below:

First NameLast Name

WHEELNUTZ GARAGE Intake Form