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Aged Care Access Support
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01
Participant Details
02
Medication Information
03
Safety Considerations
04
OHS & risk assessments
Participant Details:
Participant Name
*
Participant Surname
*
Do you have a preferred gender and/or pronoun?
*
Select value
Male
Female
Intersex or Indeterminate
Do not wish to disclose
Other – provide details below
Preferred Gender
Preferred Pronoun
Are you an Aboriginal or Torres Strait Island descent?
*
Yes
No
Preferred Name
*
Date of Birth
*
Residential Address Details:
Number / Street
*
State
*
Postcode
*
Postal Address Details:
Number / Street
*
State
*
Postcode
*
Participant Contact Details:
Email
*
Home Phone No
Mobile No
*
Choose Your Service
NDIS
My Aged Care
NDIS
NDIS Number
*
NDIS Start Date
*
NDIS End Date
*
My Aged Care:
AC Number
*
My Aged Care Referral Code
*
Funding Type:
Funding Type
Self-Managed
Plan-Managed
NDIA-Managed
Others
Funding Details
Representative details (if applicable):
Surname
Name
Relationship with the participant
Phone No
Mobile No
Email
Address Details
Postal Address Details
Other Information:
Country of Birth
*
Number of years in Australia (if not born in Australia)
The main language spoken at home
*
Culture, Communication & Intimacy:
Are there any cultural, communication barriers or intimacy issues that need to be considered when delivering services?
No
Yes
Verbal communication or spoken language - Is an interpreter needed?
*
Yes
No
Specify Language
*
Cultural values/ beliefs or assumptions
*
Cultural behaviours
*
Written communication/literacy
*
Physical Profile
Weight
KGs (Kilograms)
Height
CMs (centimetres)
Eye Colour :
Brown
Hazel
Green
Blue
What is your build?
Small
Medium
Large
Facial Hair?
Yes
No
Birth Marks?
Yes
No
Tattoos?
Yes
No
What is your complexion?
Fair
Light
Olive
Dark
Hair Colour :
Brown
Blonde
Red
Black
Grey
Bold
Emergency Details (Primary Contact)
Contact Name
*
Relationship
*
Home Phone No
Mobile No
*
GP Medical Contact
Clinic Name
Email Address:
Surname
First Name
Address
Telephone Number
Mobile Phone Number
Support Coordination Details:
Contact Name
Phone Number
Relationship
Specialist Medical Contact/Behaviour Support Practitioner (if applicable)
Do you see a specialist for a medical condition/disability?
No
Yes
Clinic Name
Email Address
Surname
First Name
Address
Telephone Number
Mobile Phone Number
Living and support arrangements
What is your current living arrangement?
*
Live with Parent/Family/Support Person
Live in private rental arrangement with others
Live in private rental arrangement alone
Aged Care Facility
Owns own home
Mental Health Facility
Lives in public housing
Short Term Crisis/Respite
Staff Supported Group Home
Hostel/SRS Private Accommodation
Other, please specify
Disability Conditions/Disability type(s)
Indicate what type of disability or disabilities this participant has including diagnosis eg: ADHD
Are there any important people in the Participant’s life such as family member and their relationship?
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