Client Support Plan

General Info

Today's Date:

Scheduled Review Date (every 6 months to a year unless otherwise agreed with the Client):

Is this the Client's first Support Plan or a review of a previous Support Plan?

Hope Health & Care Services Representative attending Support Planning meeting:

Other persons involved in Support Planning:

Client Name:

Client DOB:

Address

My preferred contact method:

Name of Enquirer:

My preferred emails:

Enquirers Contact:

How is Enquirer related:

ATSI lnformation

Aboriginal but not Torres Strait lslander origin

Torres Strait lslander but not Aboriginal origin

Both Aboriginal and Torres Strait lslander origin

Neither Aboriginal or Torres Strait lslander origin

Prefer not to answer

Living Arrangements: (Who Do You Live With?)

Living Environment (e.g. Unmodified Or Modified Home/Unit For My Needs, Support Accommodation)

Representative of Client's Name: (if applicable)

Address

Home phone:

Mobile:

Work:

Email

Diagnosis:

Date of Diagnosis:

Medical History:

GP Name:

Address:

Work ph:

Email:

Communication

Type

Verbal

Non-Verbal

Communication aids required

Other:

Are you of a culturally or linguistically diverse background?

Yes

No

Do you have any culture, diversity, values and beliefs of which we should be aware?

Yes

No

Languages Spoken

English

Other:

Is an lnterpreter required?

No

Yes, because Client is hearing impaired

Yes, for language reasons

Yes, to ensure the support plan is provided to the Client in the mode of communication and terms they are most likely to understand.

I express emerging health concerns by:

System for escalation in urgent health situations.

A bit about you and your goals and support needs

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

My Strengths are (what I am good at)...

I like

I don't like... (please include any sensory considerations)

You will know when I am happy by...

You will know when I am unhappy by...

I prefer to communicate by...

What are your goals for the next 12 months?

How have these goals changed since your previous Support Plan (if applicable)

How do your existing support from us or other providers help achieve desired outcomes? ls there any opportunity to use less intrusive options, in accordance with contemporary evidence-informed practlces that meet participant needs and help achieve desired outcomes.

NDIS Funding Info

Are you receiving any support or services from other providers? lf so, please list

Are you happy for us to develop and maintain links, collaborate with and share information with these to help meet your needs?

Yes (if so, in relation to some or all providers. List below)

No (if so, in relation to some or all providers. List below)

About your weekly schedule

Time	Monday	Tuesday	Wednesday	Thursday	Friday	Saturday	Sunday
6.00-7.00 am
7.00-8.00 am
8.00-9.00 am
9.00-10.00 am
10.00-11.00 am
11.00-12.00
12.00-1.00 pm
1.00-2.00 pm
2.00-3.00 pm
3.00-4.00 pm
4.00-5.00 pm
5.00-6.00 pm
6.00-7.00 pm
7.00-8.00 pm
8.00-9.00 pm
9.00-10.00 pm +

Mealtime Management

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

Mental Health

I have/experience...

Depression

Psychosis

Bipolar

Anxiety

Schizophrenia

Other

I would like Hope Health & Care Services to help me manage this by...

My triggers may include...

I am supported/linked with the following organisations who assist me.. (Please supply relevant management plans.)

I have received medical support to assist me and Hope Health & Care Services has a copy of any relevant management plans to help me manage.

Functional Requirements

Activity	Tick one	Domestic and Parsonal Care	Provide details of the aids and assistance required, from whom and when
Housework		Can maintain home without help (including laundry)
		Need some assistance (cleaner, change light bulb)
		Completely unable to do housework
Transport		No help needed (drives own car, or travels independently on public transport or by taxi)
		Need some help (someone to drive or accompany when travelling)
		Can only travel in specialised vehicle
Shopping (has transport)		Can take care of all shopping needs on own (including internet shopping)
		Need some help (someone to accompany on most shopping trips)
		Completely unable to do any shopping
Meal Preparation		No help needed (can plan, prepare, cook and ensrure nutrition)
		Need some help
		Completely unable to prepare meals and manage nutrition
Eating		No help needed
		Some help needed (cutting up food, spreading butter, pouring drink, modified cutlery)
		Completely unable to eat without help (spoon feeding)
Taking oral medication		No help needed (right dose and right time)
		Need some help (someone prepares, reminds, pre-packed)
		Completely unable to take own medicines without help
Handling money		No help needed (banking, paying bills, keeping track of finances)
		Need some help (can manage day to day buying but needs help with paying bills)
		Completely unable to manage money
Telephone		No help needed (can make and receive phone calls including using assistive devices)
		Needs some help
		Completely unable to use telephone
Mobility		No help needed (except use of stick)
		Need some help (person, walker, crutches or self-propelled wheelchair including cornering)
		Completely unable to walk or needs to be pushed in wheelchair
Transfer Bed/chair		No help needed
		Need some help (person or equipment)
		Unable to manage (unable to balance while sitting)
Bathing Showering		No help needed (get in and out of bath/shower and wash unaided)
		Need some help (rails, shower chair, person lo shampoo hair) but can wash themselves
		Completely unable to bath/shower on own
Oral care		No help needed (includes using electric toothbrush)
Oral care		Need some help (prompting)
		Completely unable to manage mouth care and cleaning teeth
Dressing		No help needed
		Need some help (zips, buttons, laces but can put on some garment)
		Completely unable to dress
Grooming (makeup, hair, nails, shaving)		No help needed
		Need some help
		Completely unable to manage any grooming without help
Toileting		No help needed (can get on and off, remove clothing and clean thoroughly)
		Need some help
		Completely unable to manage toileting without help

Health requirements

Activity	Tick (as applicable)		Outline condition, treatments, aids/assistance required, from whom and when
Medical		Have had a GP check up in the last 12 months
		See a specialist regularly
		Have a case manager/support coordinator
Vaccinations		Vaccinations have been up to date and all existing documentation regarding vaccination is obtained
		No written record of vaccinations (in which case, catch-up immunisation is recommended)
		lmmunisations booked
Dental		Have had a dental check up in the last 12 months
		See a dentist regularly
		Dental check booked
Allied Health		Have had an allied health check up in the last '12 months by a physio, occupational therapist, psychologist or other allied health practitioner
		See an allied health practitioner regularly
		Allied health practitioner booked
Continence		Continent with regular bowel and bladder action
		Constipation, diarrhoea or incontinence (using medication, supplements, pads)
		Medical interventions (catheter, stoma bag)
Skin Integrity		No skin problems
		Some skin problems (rash, skin treatments)
		Pressure areas (currently have, at risk, or had in past)
Swallowing		No swallowing lssues
		Some swallowlng problems (choking, coughing during normal meal, reduced appetite)
		Maior swallowing difficulties (modified diet, feeding tube)
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 comorbidities

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 & Interests:
Rellgion & Spirituality
Outings: E.g. theatre, cafes, exhibition, 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

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 supporting you?	Provide details	Notes in relation to potential workers discussed with client who could provied supports (given preferences below and relevent training of workers to deliver such supports)
Muscular issues (other than pain)	Male
	Female
	No preference
	Intrusive support?
Where the Client has 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 for this Client?

Do the contemplated Workers that are proposing to provide these supports have such training?

Conclusion: About Your support worker

Their name is:

A bit about them:

Consent, internal checks and administrative requirements

signature*

Terms of Agreement