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HOMECARE
Home Care - Assistance with Daily Life
Community Nursing Care
ACCOMMODATION
Short Term Accommodation
Medium Term Accommodation
Specialist Disability Accommodation
COMMUNITY SUPPORT
Support Co-ordination
Assistance with Social and Community Participation
Specialist Disability Accommodation
Supported Independent Living
Development and Life Skills
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HOME CARE
Home Care – Assistance with Daily Life
Community Nursing Care
ACCOMMODATION
Short Term Accommodation
Medium Accommodation
Specialist Disability Accommodation
COMMUNITY SUPPORT
Support Co-ordination
Assistance with Social and Community Participation
Supported Independent Living
Development and Lifeskills
Our Events
Gallery
Careers
Join Our team
Feedback
Our Policies
For Referral
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Referral
Intake Referral Form
Step
1
of
4
25%
Participant Name
Full Name
First
Last
Address
Street Address
Email
Your Contact Number
Date of Birth
MM slash DD slash YYYY
Other name
(if known by any other name)
Do you have a legal guardian?
Yes
No
If so, please provide:
Address
Email
Phone
Next of Kin
Name
Address
Telephone
Mobile Phone
Emergency contact
(if different to above)
Personal Information:
NDIS Plan Number
(Required)
NDIS Plan Number
NDIS Plan Start Date
NDIS Plan Expiry Date
Plan managed / NDIA Managed/ Self-Managed?
Add
Remove
What is your diagnosis?
Age Group
Under 7
7-18
18 -65
65+
Pronouns
Cultural Identity
Language/Communication needs
Are there any requirements for your support worker?
E.g., specific gender, fluent in another language, religious background
What is your diagnosis group?
What services are you requesting from SOLW
Assistance with Daily Life;
Assistance with Social;
Economic and Community Participation;
Transport;
Home and Living;
Support Coordination;
Plan Management.
This field is hidden when viewing the form
What services are your seeking?
Tick your preferred box to display the list of services.
Low Risk
High Risk
Highest Risk
Low Risk Service
Household Tasks
Innovative Community Participation
Specialised Driver Training
Custom Prostheses and Orthoses (Custom Prosthetics)
Vehicle modifications
Assistance with Travel/Transport arrangements
Assistive Technology and Equipment
Accommodation/Tenancy Assistance (Accommodation/Tenancy)
Community Nursing Care
Therapeutic supports (Allied Health Groups)
Home Modification Design and Construction (Home Modification)
Management of Funding for Supports (Plan Management)
Assistance Animals
High Risk Service
Assistance to Access and Maintain Employment or Higher Education
Development of Daily Living and Life Skills
Daily Personal Activities (see prompts below)
Group and Centre Based Activities
Assistance with Daily Life Tasks in a Group or Shared Living Arrangement (SIL)
Participation in Community, Social and Civic Activities
Specialised Supported Employment
Assistance in Coordinating or Managing Life Stages, Transition and Supports (Support Coordination level 1 and 2)
Specialist Support Coordination (level 3)
Early Childhood Intervention (Childhood)
Specialised Disability Accommodation (Dwelling)
Daily Personal Activities
Capacity Building
Personal Care and Assistance in Daily Living
Capacity Building
Select All
Meal planning and preparation
Support with your health and wellbeing
Travel training including road safety and using public transport.
Support to develop social networks and friendships.
Training and support to maintain your accommodation.
Assistance with budgeting and managing finances.
Support with literacy and numeracy
Help with government departments and bills.
Personal Care and Assistance in Daily Living
Select All
Personal Care
Grocery shopping
Meal planning and preparation
Assistance with medical needs
Healthy lifestyle support
Travel training
Highest Risk Service
Bowel care
Catheter care
Subcutaneous injection
Tracheostomy care
Ventilator care
Severe dysphagia care
Wound or pressure care
PEG feeding
Diabetes care
Seizure care
Stoma care
Mealtime management care (swallowing, diabetes, allergy/anaphylaxis, diabetes, CV Disease, obesity, eating disorder
Implementation of a restrictive practice
Living Arrangements:
What are the current living arrangements?
E.g., Mum and dad, living alone, hostel or boarding house?
Which location is this in?
Have you ever been refused service or had your service cancelled? If so, please tell us about the situation. It doesn’t mean we can’t service you, but we would like to know how to better support you?
Service Delivery
What are the goals for care?
What is the support ratio?
E.g., 2:1, 1:1
Why is this support ratio needed?
Will this ratio change over time?
Are any types of transport needed?
E.g., Wheelchair accessibility
Do you have a risk profile or transition plan?
If coming from another provider or from a hospital a participant is entitled to transition plan being developed by the previous provider.
Is this an ongoing service or a single instance?
What is your preferred start date?
Do you have a current OT assessment?
Do you require assistance with medication, is this prompting, assisting, or administering?
If there are behaviours of concern, is there a behaviour support practitioner in place? And is there a behaviour support plan?
Name of Behaviour Support Practitioner?
Do you have a criminal history?
What type, if any, of manual handling is needed?
SIL:
Are you already approved for SIL or SDA?
Date available to move in?
Please provide some info/diagnosis for why you are eligible for SIL.
Funding:
How many support hours are needed?
If this is above our capacity, are you willing to share care?
Are there any funding limitations?
Other:
Is there anything else you want us to know?
Terms and Conditions
(Required)
I agree to the terms and conditions.
Privacy and Confidentially
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