ABN 16 271 279 713

CLIENT SUPPORT PLAN

Is this your first support plan or a review? *

Persons involved in Support Planning *

CareSpace Representative

About Me

Last Name *

First Name *

NDIS Number *

DOB *

Client Address *

Phone Number *

Email

Preferred Language

Cultural Background and Preferences

Do you identify as... *

Aboriginal Torres Strait IslanderBoth Aboriginal and Torres Strait IslanderNeither Aboriginal or Torres Strait IslanderPrefer not to answer

Living Arrangements (who do you live with?) *

Accommodation *

HouseUnitApartmentSupported LivingOther

Emergency Contacts

Emergency Contact 1

Name

Phone/Email

Relationship

Emergency Contact 2

Name

Phone/Email

Relationship

Emergency Contact 3

Name

Phone/Email

Relationship

Health & Medical Information

Allergies / Alerts *

Primary Disability / Impairment *

Medical Conditions *

Heart DiseaseDiabetesAsthmaEpilepsyAnxietyHigh Blood PressureOtherNone

Other conditions not listed above

GP Details

Name

Practice

Phone/Email

Chemist Details

Name

Practice

Phone/Email

Medication

Medication ListSupport Plans must include clear instructions, agreed with the participant, about what steps staff will take to help the participant with their medication.

Dietary Requirements

Food allergies *

Dietary Requirements *

VegetarianVeganGluten FreeCeliacLactose IntoleranceDiabeticNone

My favourite food is... *

I am unable to eat... (sensory/intolerances) *

Support Required With Feeding

I can identify what foods are safe for me to eat.

I prefer to provide my own food and will do so.

If I have a food allergy, I have provided CareSpace with a management plan.

If required, I will bring any medications to assist with managing my allery and have completed relevant medical forms.

Mental Health

I have/experience *

DepressionAnxietyPsychosisSchizophreniaBipolarOtherNone

CareSpace can support me with this diagnosis by...

My triggers may include...

I am supported/linked with the following organisations who assist me...

I have received medical support to assist me and CareSpace have a copy of any relevant management plans to help support me.

Your Goals & Support Needs

My Strengths Are... *

My hobbies include... *

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

You will know I am happy when... *

You will know I am unhappy when... *

I prefer to communicate by... *

My goals for the next 12 months include... *

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

Functional Requirements

Housework *

Can maintain home without help (including laundry)Need some assistance (cleaner, changing light bulb, etc)Completely unable to do housework

Provide details of the aids and assistance required.

Transport *

Independent (drives own car or travels independently on public transport/taxi)Needs some support (someone to drive or accompany when travelling)Can only travel in a specialised vehicle

Provide details of the aids and assistance required.

Shopping

Can manage all shopping needs on own (including online shopping)Requires some support (someone to accompany on most shopping trips)Completely unable to manage shopping

Provide details of the aids and assistance required.

Meal Preparation

No support needed (can plan, prepare, cook and ensure nutrition)Need some supportCompletely unable to prepare meals and manage nutrition

Provide details of the aids and assistance required.

Eating

No support requiredSome help needed (cutting up food, spreading butter, pouring drink, modified cutlery)Completely unable to eat without help (spoon/PEG feeding)

Provide details of the aids and assistance required.

Taking Oral Medication

No support required (manages independently)Requires some help (prompting)Completely unable to administer own medications without help

Provide details of the aids and assistance required.

Handling Money

No support needed (banking, paying bills, keeping track of finances)Requires some support (can manage day to day purchasing items but requires support paying bills)Completely unable to manage money

Provide details of the aids and assistance required.

Telephone

No helped needed (can make and receive phone calls including using assistive devices)Needs some helpCompletely unable to use telephone

Provide details of the aids and assistance required.

Mobility

No help needed (except use of walking stick)Need some help (person, walker crutches or self-propelled wheelchair including cornering)Completely unable to walk or needs to be pushed in wheelchair

Provide details of the aids and assistance required.

Transfers (Bed/Chair)

No support neededNeed some support (person or equipment)Unable to manage (unable to balance whilst sitting)

Provide details of the aids and assistance required.

Bathing/Showering

No support needed (can get in and out of bath/shower and wash unaided)Requires some support (rails, shower chair, person to shampoo hair) but can wash themselvesCompletely unable to bathe/shower on own

Provide details of the aids and assistance required.

Schedule of Support

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Sunday

Risk

Risk Summary

Outline any potential risks identified and strategies to mitigate them.

Description of Risk

Risk Level

HighMedLow

Action

Add another risk

Description of Risk

Risk Level

HighMedLow

Action

Please upload a copy of any additional Risk Assessment material

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NDIS Funding Information

Support Plan Agreement

Signatures

By signing this Support Plan, I agree that I have been involved in the development of my plan of care, my goals and the services required. *

Participant/Representative Signature *

Draw signature|Type signatureClear

Date *

Participant/Representative Name *

Scheduled Review Date (Annually or earlier if agreed with the client) *

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