Just Living Pty Ltd - Referral Form/Intake Questionnaire
Your answers help us (Just living) to determine eligibility and fit. Please provide as much detail as possible.
Participant Details
Full Name of participant
Date of Birth
Gender
Select an option
Male
Female
Non-binary
Prefer not to say
Pronouns
Select an option
He/Him
She/Her
They/Them
Prefer not to say
Participant phone number
Participant Email
Participant address
Who is the primary contact
Participant
Support Coordinator
Guardian &/or Nominee (enter details below)
Guardian &/or Nominee name
Relationship to participant
Guardian/ Nominee phone number
Guardian/ Nominee email address
NDIS Number
NDIS Plan Dates
How are Funds Managed?
Agency Managed (NDIA)
Plan Managed
Self Managed
if Plan Managed, please provide Company name & Email address
Disability & Important Medical Information
Language & Communication Needs?
Details of any special requirements, religious or cultural considerations/Identity
Current Living Arrangements (select all that apply)
Alone
With Parent(s)/Guardian(s)
With partner
With partner and dependents
With Dependent(s)
Share Accommodation
Boarding House/Hostel
Hospital/medical facility
With Friends/family
Other
What would you like Just Living to be assisting you with? select all that apply
Mealtime management Care (swallowing, diabetes, allergy/anaphylaxis, diabetes)
Mobility/Transport with wheelchair
Transport - general appointments, shopping etc
Medications
Capacity Building eg. meal planning, preparation, assistance with budgeting etc
Community Participation/Social Support
Mentoring
Personal Care (showering, dressing etc)
SIL (Support Independent Living)
Respite & /or STA (Short Term Accommodation)
MTA (Medium Term Accommodation)
What is the funded Support Ratio? Support Worker(s) :to Participant(s)
1:1 (1x Support Worker to 1x Participant)
1:2
1:3
2:1 (2x Support Worker to 1x Participant)
Are there any other Service Providers we will be interacting with?
Yes - please provide details below
No
Please provide details of other providers
Is there an Speech Pathologists report available/mealtime management plan?
Yes - Please upload
No
Pending
Upload Speech Pathologists Report
Select a File
Is there an Occupational Therapists (OT) report available?
Yes - Please upload
No
Pending
Upload Occupational Therapists (OT) Report
Select a File
Are there any behaviours of concern (BOC)?
Yes - Please provide summary below & upload PBS plan if available
No
Pending
Are there any authorised restrictive practices in place? eg. chemical restraint, legal curfews
Yes
No
Please provide further information on any restrictive practices or BOC if a PBS Plan is NOT available
Please upload PBS Plan if available
Select a File
Will the participant require medication prompting or assisting?
They have no medications
They can medicate themselves 100%
They only require prompting, can physically administer
They will require assisting, as they may take the wrong medication &/or at the wrong time or dosage
They will need medications administered
Does the Client experience Seizures?
Yes
No
Is the Participant currently living in Supported Independent Living (SIL)?
Yes - If Yes, can you please provide further information below
No
Please provide more information about current supports
Reason for Referral
Supports Required from Just Living (SIL, STA, Respite, Community &/or Social Supports)
Are the Support days Flexible?
Yes, please include any details above
No, please include any details above
Are the shift times flexible?
Yes, please include any details above
No, please include any details above
Supports Worker Requirements
What interests and hobbies does the participant have &/or would like to have
Participant Strengths
Further Information
Can you provide the Participants NDIS Plan?
Select a File
If there is anything else we would benefit from knowing, please include this information here.
Details of referring provider
Full Name
Relationship
Service Provider
Phone Number
Email
Your Signature
*
Clear
Date
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