Strivesocial: Participant Support Plan
Participant Support Plan
Participant information
Participant Name
DOB
Phone
Address
Living Arrangement (e.g. alone, with family, in unmodified or modified home/unit, support accommodation)
Today’s Date:
Scheduled Review Date (6-12 months unless otherwise agreed with the Participant):
First Plan or Plan Review?
Worker Name:
Is the Participant Aboriginal and Torres Strait Islander(ATSIC)?
Does the Participant need access to ATSIC services
Disability/Diagnosis
Health conditions (Physical, Mental Health etc)
GP Name (if applicable)
GP Contact Details (if applicable)
Is there anyone the Participant would like involved in the support plan?
Does the Participant have a Representative such as a nominee or guardian?
Representative Name (if applicable)
Representative Contact Details (if applicable
What is your preferred communication style or contact method? (Tick all that apply)
☐ Face to face
☐ Phone
☐ Email only
☐ Follow up with phone call
☐ Zoom
☐ Lots of reminders
☐ Do not communicate with me
☐ Easy English
☐ Social Media Service
Emergency Arrangements
Has a Participant Emergency Plan been completed in collaboration with the participant?
☐ Yes
☐ No
If answered No, specify why: (e.g. not relevant due to online supports etc
Are there any specific support needs that we need to consider if there was an emergency or disaster?
Communication
Type
☐ Verbal
☐ Non-Verbal
☐ Communication aids required
☐ Other:
Are you of a culturally or linguistically diverse background?
☐ Yes
☐ No
Languages Spoken
☐ English
☐ Other
Details:
Is an Interpreter required?
☐ Yes
☐ No
Do you have any culture, diversity, values and beliefs of which we should be aware?
☐ Yes
☐ No
If Yes please provide details
How Participant expresses emerging health concerns
Systems for escalation in
urgent health situations
What is your preferred communication style or contact method? (Tick all that apply)
☐ Face to face
☐ Phone
☐ Email only
☐ Follow up with phone call
☐ Zoom
☐ Lots of reminders
☐ Do not communicate with me
☐ Easy English
☐ Social Media Service
NDIS Funding Information
NDIS plan number:
Funding Type
☐ Self Managed
☐ Plan Managed
☐ NDIA Managed
Plan start date:
Plan end date:
Appropriate Funding Available
☐ Yes
☐ No
Which Funds Available
☐ Core Supports
☐ Capacity Building Supports
☐ Capital Supports
Plan Managers Details (if applicable)
Has a copy of the plan been provided?
☐ Yes
☐ No
Are any supports being provided by another provider
☐ Yes
☐ No
Other Providers Details (if applicable)
Is the Participant happy for us to collaborate with and share information to assist in service provision?
☐ Yes
☐ No
List Service Providers to collaborate with (if applicable)
How can we assist you
Which services are you interested in?
What are your preventative Health Needs?
Do you need our support to access dentist appointments, vaccinations or other allied health services?
Functional Requirements
Requirement
Applicability
Details of aid/assistance required
Housework
☐ Needs Assistance
☐ No Assistance Needed
Transport
☐ Needs Assistance
☐ No Assistance Needed
Shopping (has transport)
☐ Needs Assistance
☐ No Assistance Needed
Meal preparation
☐ Needs Assistance
☐ No Assistance Needed
Eating
☐ Needs Assistance
☐ No Assistance Needed
Taking oral medication
☐ Needs Assistance
☐ No Assistance Needed
Handling money
☐ Needs Assistance
☐ No Assistance Needed
Telephone
☐ Needs Assistance
☐ No Assistance Needed
Mobility
☐ Needs Assistance
☐ No Assistance Needed
Transfers Bed/chair
☐ Needs Assistance
☐ No Assistance Needed
Bathing/Showering
☐ Needs Assistance
☐ No Assistance Needed
Oral care
☐ Needs Assistance
☐ No Assistance Needed
Dressing
☐ Needs Assistance
☐ No Assistance Needed
Grooming (makeup, hair, nails, shaving)
☐ Needs Assistance
☐ No Assistance Needed
Toileting
☐ Needs Assistance
☐ No Assistance Needed
Health requirements
Requirement
Applicability
Details of aid/assistance required
Medical Checkups
☐ Needs Assistance
☐ No Assistance Needed
Dental Appointments
☐ Needs Assistance
☐ No Assistance Needed
Allied Health Appointments
☐ Needs Assistance
☐ No Assistance Needed
Vaccination Appointments
☐ Needs Assistance
☐ No Assistance Needed
Continence
☐ Needs Assistance
☐ No Assistance Needed
Skin Integrity
☐ Needs Assistance
☐No Assistance Needed
Swallowing
☐ Needs Assistance
☐ No Assistance Needed
Muscular pain
☐ Needs Assistance
☐ No Assistance Needed
Nerve pain
☐ Needs Assistance
☐ No Assistance Needed
Falls
☐ Needs Assistance
☐ No Assistance Needed
Muscular issues (other than pain)
☐ Needs Assistance
☐ No Assistance Needed
Other health concerns
☐ Needs Assistance
☐ No Assistance Needed
Behavioural Requirements
Issue
Applicability
Details of aid/assistance required
Communication
☐ Needs Assistance
☐ No Assistance Needed
Memory
☐ Needs Assistance
☐ No Assistance Needed
Concentration
☐ Needs Assistance
☐ No Assistance Needed
Planning
☐ Needs Assistance
☐ No Assistance Needed
Decision Making
☐ Needs Assistance
☐ No Assistance Needed
Mood
☐ Needs Assistance
☐ No Assistance Needed
Social Requirements
Activities
Applicability
Activity details (type, time spent, the assistance required)
Family
☐ Needs Assistance
☐ No Assistance Needed
Hobbies & Interests
☐ Needs Assistance
☐ No Assistance Needed
Religion & spirituality
☐ Needs Assistance
☐ No Assistance Needed
Outings
☐ Needs Assistance
☐ No Assistance Needed
Computer
☐ Needs Assistance
☐ No Assistance Needed
Employment
☐ Needs Assistance
☐ No Assistance Needed
Sports
☐ Needs Assistance
☐ No Assistance Needed
Music
☐ Needs Assistance
☐ No Assistance Needed
Movies/TV
☐ Needs Assistance
☐ No Assistance Needed
Food and alcohol
☐ Needs Assistance
☐ No Assistance Needed
Sex and intimacy
☐ Needs Assistance
☐ No Assistance Needed
Other
☐ Needs Assistance
☐ No Assistance Needed
Mealtime Requirements
Requirement
Applicability
Details (if applicable)
Allergies
☐ Yes
☐ No
Intolerances
☐ Yes
☐ No
Vegetarian
☐ Yes
☐ No
Vegan
☐ Yes
☐ No
Other dietary requirements
☐ Yes
☐ No
Meal Plan Prepared
☐ Yes
☐ No
Nutrition or Swallowing Issues
☐ Yes
☐ No
Seating/Positioning requirements while eating or drinking
☐ Yes
☐ No
Any Food Preparation Requirements?
☐ Yes
☐ No
Your Goals
How do you see us supporting you with this?
Goal 1:
Goal 2:
Goal 3:
Goal 4:
Strengths
What are your strengths? Tell us how we can help utilise them while we support you
Strengths can be things like - I’m patient, I’m empathetic, I am great at time management, I am very loving, I am a hard worker etc.
Worker Matching
We value getting the right Worker match for your needs considering factors like personality, language, culture, and skills. We want you to be part of this matching process and can help you find an advocate if you wish. Can you tell us about the characteristics you'd like in your Support Worker?
What else would you like us to know?
Administration Requirements
Has this document been completed with the participant?
☐ Yes
☐ No
Has a Risk Assessment Form been completed with the Participant?
☐ Yes
☐ No
Would you agree to let us arrange for a qualified and/or experienced worker from Strivesocial to temporarily provide support to you, should there be an emergency or if your regular worker is unavailable?
☐ Yes
☐ No
If an emergency arises, would you permit us to collaborate with an external agency or contractor for short-term assistance, or to fill the position if needed?
☐ Yes
☐ No
If an unplanned absence turns into a permanent one, are you comfortable with us finding a new worker to permanently take on the role?
☐ Yes
☐ No
Would you like us to share details about your support plan with your family, caregivers, other service providers, and pertinent government agencies?
☐ Yes
☐ No
Is this support plan stored in a location where the Participant can easily access it?
☐ Yes
☐ No
Is the support plan kept in a place that's easily accessible to Strivesocial?
☐ Yes
☐ No
Has an Individualised Plan been developed for this Participant in case of emergencies?
☐ Yes
☐ No
Please sign below to indicate your consent to the prepared Participant Support Plan:
Strivesocial’s Representative Name:
Signature:
Date:
Participant’s Worker’s Name:
Signature:
Date:
Participant Name:
Signature:
Date:
Participant’s Representative Name (if applicable):
Signature:
Date:
Interpreter Name (if applicable):
Signature:
Date: