Support Plan

Support Plan Start Date

Support Plan Review Date (Annual)

Support

Description

How the support will be provided

First Name

Last Name

Date of Birth

Gender

Male Female Prefer not to say

Aboriginal or Torres Strait Islander Origin?

No Yes, Aboriginal Yes, Torres Strait Islander Yes, both Aboriginal and Torres Strait Islander

Cultural Background and Preferences

Preferred Language

Interpreter Required?

Yes No

Privacy Preference

Financial Management Arrangements

Participant Contact Information

Current Address

Street Address

Street Address Line 2

State/Province

Postal / Zip Code

Mobile Phone

Email Address

Emergency Information

Name

Relationship

Phone Number

Does the participant require assistance in an emergency?

Yes No

Details of emergency support required:

Does the participant have a Personal Emergency Alarm?

Yes No

Details of personal emergency device:

GP Details

First Name

Last Name

Practice

Phone Number

Email Address

Medication Required

Yes No

Prompt Required

Yes No

Assistance Required

Yes No

Administration Required

Yes No

Please Give Details

Decision Making, Health and Medical Information

Name

Role/Relationship

Phone Number

Allergies

Disability, Diagnosis or Medical Conditions

COVID-19 Vaccination Status

Full Vaccination Booster of 3 doses 2 doses of a COVID-19 vaccine1 dose of a COVID-19 vaccine Has not received a COVID-19 vaccine Participant is exempt due to medical reasons

General Practitioner Details

Name

Practice

Phone

Is Medication required?

Yes No

Is Assistance and Administration required?

Yes No

Provide details of participant's Medication:

Describe any ongoing health issues the participant has, including mental health issues:

Does the participant have a health or mental health care plan?

Yes No

Please upload health/mental health care plan

Is the participant currently receiving end of life care/have an End of Life Care Plan?

Yes No

Please upload End of Life Care Plan

Does the participant have a signed DNR Order in place?

Yes No

Please upload signed DNR Order

Preventative Health Measures

Disablity Supports

Mobility

Needs assistance Does not need assistance Is independent Is not independent

Details and Aids used

Needs assistance Does not need assistance Is independent Is not independent

Hearing

Nil issues Some issues Hearing impaired

Details and Aids used

Vision

Nil issues Some issues Hearing impaired

Details and Aids used

Memory Cognition

Nil issues Some issues Hearing impaired

Details and Aids used

Communication

Needs assistance Does not need assistance

Details and Aids used

Continence

Needs assistance Does not need assistance

Details and Aids used

Daily Living Supports

Showering/Bathing

Details

Transfers (mobility)

Details

How often does the participant require supervision or support throughout the day?

None of the time All of the time During active times (e.g. getting ready, eating meals, going out, etc.)

Details

How often does the participant require supervision or support throughout the night?

None of the time All of the time During active times (e.g. toileting, transfers, behaviours, etc.)

Details

Participant's Behaviour Supports

Does the participant have a current Positive Behaviour Support Plan?

Yes No

Please upload current PBSP

Does the participant require a Functional Behaviour Assessment or Restrictive Practice Behaviour Support Plan regarding behaviours of concern?

Yes No

Does the participant display or engage in any behaviours of concern that require specific support?

Does the participant have a current risk assessment relating to their behaviour or support needs?

Yes No

Please upload current risk assessment

Additional Information

Does the participant need assistance getting around the community?

What type of transport does the participant mainly use?

Does the participant need assistance to use transport?

Does the participant engage or participate in any recreational, community based, employment or training activities?

Does the participant need assistance to access any of these activities?

Risk Assessment

Risk Description

Risk Level

Action

Participant's NDIS Goals

Participant's personal preferences (likes/dislikes)

Goals for support

Supports provided

I, undersigned, agree with the following statements:

I agree that I have been involved in the development of my plan of care, my goals and the services required. I agree that I have given permission for my Support Plan to be distributed only to the people involved in the development and support of my care including nominated advocates/representatives and may be included in any referrals made on my behalf.

1800 953 800

UpCare Support Plan Request Form

Complete The Following Form

Support Plan

Participant Contact Information

Emergency Information

GP Details

Decision Making, Health and Medical Information

General Practitioner Details

Disablity Supports

Daily Living Supports

Participant's Behaviour Supports

Risk Assessment

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