Support Plan

Support Plan Start Date
28/07/2024

Support Plan Review Date (Annual)
28/07/2024

Support
SIL

Description

How the support will be provided

Name
First Name

Last Name

Date of Birth
Date

Gender
FemaleMaleOther

Aboriginal or Torres Strait Islander Origin?
NoYes, AboriginalYes, Torres Strait IslanderYes, both Aboriginal and Torres Strait Islander

Cultural Background and Preferences

Preferred Language

Interpreter Required?
YesNo

Privacy Preferences

Financial Management Arrangements

Participant Contact Information

Current Address
Street Address

Street Address Line 2

City

State/Province

Postal / Zip Code

Mobile Phone
Please enter a valid phone number.

Email Address
example@example.com

Emergency Information

Emergency Contact Details

Name

Relationship

Phone Number

Does the participant require assistance in an emergency?
YesNo

Details of emergency support required:

Does the participant have a Personal Emergency Alarm?
YesNo

Details of personal emergency device:

GP Details

Name
First Name

Last Name

Practice

Phone Number
Please enter a valid phone number.

Email Address
example@example.com

Pharmacist Details

Name
First Name

Last Name

Practice

Phone Number
Please enter a valid phone number.

Email Address
example@example.com

Medication

Medication Required
YesNo

Prompt Required
YesNo

Assistance Required
YesNo

Administration Required
YesNo

Please Give Details
Support Plans must include clear instructions, agreed with the participant, about what steps staff will take to help the participant with their medication.

Decision Making

Please specify all the people assisting the Participant with decision making

Decision Maker Contact Details

Name

Role/Relationship

Phone Number

Health and Medical Information

Allergies

Disability, Diagnosis or Medical Conditions

COVID-19 Vaccination Status
Full Vaccination Booster of 3 doses2 doses of a COVID-19 vaccine1 dose of a COVID-19 vaccineHas not received a COVID-19 vaccineParticipant is exempt due to medical reasons

General Practitioner Details

Name

Practice

Phone Number
Please enter a valid phone number.

Email
example@example.com

Medication Details

Is Medication required?
YesNo

Is Assistance and Administration required?
YesNo

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?
YesNo

Please upload health/mental health care plan

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

Please upload End of Life Care Plan

Does the participant have a signed DNR Order in place?
YesNo

Please upload signed DNR Order

Preventative Health Measures
If support is required by the participant, what arrangements are in place to proactively support the participant with preventative health measures, including helping them to access recommended vaccinations, dental check-ups, comprehensive health assessments, and allied health services?

Preventative Health Measures
Where health needs are identified, what is the agreed process that needs to be followed to escalate and respond to medical emergencies?

Disability Supports

Mobility
Needs assistanceDoes not need assistanceIs independentIs not independent

Details and Aids used:

Hearing
Nil issuesSome issuesHearing impaired

Details and Aids used:

Vision
Nil issuesSome issuesHearing impaired

Details and Aids used:

Memory/Cognition
Nil issuesSome issuesHearing impaired

Details and Aids used:

Communication
Needs assistanceDoes not need assistance

Continence
Needs assistanceDoes not need assistance

Details and Aids used:

Daily Living Supports

Day and Night Supports

How often does the participant require supervision or support throughout the day?
None of the timeAll of the timeDuring 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 timeAll of the timeDuring active times (e.g. toileting, transfers, behaviours, etc.)

Details:

Participant's Behaviour Supports

Does the participant have a current Positive Behaviour Support Plan?
YesNo

Please upload current PBSP

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

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?
YesNo

Please upload current risk assessment

Additional Information

Community Participation Supports

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

Refer to your completed participant risk assessment to complete the following section

Risk Summary

Risk Description

Risk Level

Action

Service Provision

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.

Support Plan

Participant Contact Information

Emergency Information

Emergency Contact Details

GP Details

Pharmacist Details

Medication

Decision Making

Decision Maker Contact Details

Health and Medical Information

General Practitioner Details

Medication Details

Disability Supports

Daily Living Supports

Day and Night Supports

Participant's Behaviour Supports

Community Participation Supports

Risk Assessment

Risk Summary

Service Provision

Contact Us

About Upcare

Customer Resources

Accreditation

Acknowledgement of Country