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Registered Agency with the Office of Children Guardians (OCG)

Client Intake Form Download PDF

Hope Health & Care Services appreciates that everyone is unique, please help us to get to know you by answering the following:

Client Details

Representative or Emergency Contact Details

About You

Communication

Consent

Dietary Requirments

I have the following allergies/intolerances and my favourite food is...

Mental Health

Physical Health

Practical Support Needs

Check the boxes which best represent you and your support needs...
Behaviour I can do independently I need a little help I cannot do independently
Traffic awareness
Staying with the group
Communicating appropriately
Looking after property
Being aware of personal space
Keeping my hands to myself
Travelling safely in a car
Following instructions
Swimming and safety around water
I can handle my own spending money
I am comfortable in my sleeping routine

A bit about you and your goals

To help us understand you better, please fill the below:

Health requirements

Activity Tick one Outline condition, treatments, aids/assistance required, from whom and when
Continence
Continent with regular bowel and bladder action
Constipation, diarrhea or incontinence (using medication, supplements, pads)
Medical interventions (catheter, stoma bag)
Skin lntegrity
No skin problems
Some skin problems (rash, skin treatments)
Pressure areas (currently have, at risk, or had in past)
Swallowing
No swallowing issues
Some swallowing problems -(choking. coughing during normal meal, reduced appetite)
Major swallowing difficulties I (modified diet, feeding tube)
Health professionals
Have had a GP check up in the last 12 months
See a specialist regularly
Have a case manager/support coordinator
Muscular pain
No pain
Moderate pain
Severe pain
Nerve pain
No pain
Moderate pain
Severe pain
Falls
No falls in past 12 months
Less than 3 falls and no serious injury from a fall in past 12 months
More than 3 falls or a serious injury from a fall in the past year
Muscular issues (other than pain)
No problems
Some muscle weakness, tremor, spasms, spasticity or problems with balance
Serious muscle weakness. tremor, spasticity or problems with balance
Other health concerns
Fatigue, visual disturbance, temperature intolerance, other co morbidities

Social Requirements

Activities Outline how you want to do this activity Provide details of the activity, the time spent, the assistance required, from whom and when (including vouchers)
Example:
I love cooking a
  • I like to watch cooking shows on TV
  • I like to buy good cook books
  • I like to prepare my own meals
  • I like to attend cooking classes regularly
  • I need a TV in my room with good reception.
  • I need a computer/tablet and high speed internet or Wi-Fi to buy books online.
  • I would like to have access to a kitchen to prepare my own meals 2 x per week
  • I need a maxi taxi and carer/staff member to take me to cooking classes once a month
Family:
Hobbies & lnterests:
Religion & spirituality
Outings:E.g. theatre, cafes, exhibitions, drives, group activities
Computer:E,g. games, shopping, education, bookings
Employment:Education, Volunteering
Sports:
Music: Likes, dislikes
Movies/TV:Likes, dislikes
Well-being:E.g. exercise, gym, swimming, massage, yoga, meditation etc...
Food and alcohol:Likes, dislikes, diets
Sex and intimacy
Other:

Behavioural requirements

lssue Tick one Assistance I need Outline the issue, aids, assistance and management strategis required
Communication
No assistance required (including independent use of aids and adaptive technology)
Some assistance required (prompting, assistance with aids)
Assistance always required
Memory problems Confusion
No
Yes
Concentration problems
No
Yes
Planning problems
No
Yes
Spiritual needs
No
Yes
Mood
Mostly positive
Experience sadness, anxiety or emptiness around 50% of time
Feelings of anxiety, sadness or empiiness lasting most of the day, nearly every day
Decision Making
No help needed
Need some help
Not able to make any decisions
Do you have a will?
No
Yes
Do you have an Enduring Power of Attorney or Guardian?
No
Yes
Do you have an Advanced Care Plan?
No
Yes
What things are important for people to understand about you when caring for you? Provide details Outline how you like this to be managed
Who makes the decisions?
What routines do you have?
What makes you happy?
What helps you relax?
What causes you stress?
What makes you frustrated?
What makes you angry?
Other

Matching

We recognise the significance of matching the right staff member to meet your needs and consider a number of factors such as personality, language, culture and skill requirements. We encourage and support you to be involved in the process of matching your needs with the right staff. We can also support you to access an advocate of your choice to support you in this process.

Based on the above, what characteristics would you like to see in any staff member supportiong you? Provide Details Notes in relation to potential Workers discussed with client who could provide supports (given preferences below and relevant training of Workers to deliver such supports)
Gender
Personality type
Languages spoken
Culture or religion
Specific needs, skills and knowledge required
Do you require any intrusive support?
Do you have any specific needs which require monitoring and/or daily support, which Workers are appropriately trained to understand the Client's needs and preferences.
What specific training may be required to provide support and services to you?
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