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Service Agreement
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Participant Details
Participant Name
Preferred Name
Gender
Male
Female
Date of Birth
NDIS Funding type
NDIS Managed
Self-Managed
Plan Managed
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NDIS number
NDIS Start Date
NDIS End Date
Marital Status
Single
Married
Divorced
Preferred contact method and details
Email
Post
Phone
Email
Post
Phone
Residential address
Do you identify as Aboriginal and Torres Strait Islander?
Yes
No
Cultural background
Religion
Language spoken at home
Do you need an interpreter?
Yes
No
Living Situation
Living alone in my own home
Living with my family
Supported Accommodation
Temporary
Other
Other (Please specify)
Preferred gender of worker
Emergency Contact
Name
Relationship
Phone
Email
Notes
Name
Relationship
Phone
Email
Notes
EPOA
EPOA (Enduring Power of Attorney) Copy Received
Allergies
Food
Medication
Others
Other (Please specify)
Alerts
((Does the participant have an asthma plan, epilepsy plan, anaphylaxis plan etc? Please provide a copy of the plan)
Participant Home Visiting Information
Participant Location/Address
Access
Front door
Back door
Other
Parking
Off street
Street
Other
Transport Arrangements
Care Giver Car
Taxi
Disability Permit
Other
Other (Please specify)
Other (Please specify)
Other (Please specify)
Background Info
Pet Details
Emergency Plan
Response Plan
if Participant is Not Home
Health Information
Relevant Medical Condition
Smoker
Yes
No
Falls Risk
Behaviours & Triggers
Emergency Pendant
Hospital Preference
Medication
Prompt Required
Yes
No
Assistance Required
Yes
No (if assistance required, a medication list must accompany this support plan)
Location
Pharmacist Details
GP Contact Details
Name
Practice
Address
Phone
Specialist Details
Name
Practice
Address
Phone
Other Allied Health Provider Details
Name
Practice
Address
Phone
Vaccinations details
Regular medical and dental check-ups and history
Medical Emergency Response Plan
Potential Health Emergency
Immediate Response
Escalation System
Contact details of organisation
About the Participant
(Participant Summary):
Goals
Short term goals
Long term goals
Participant Likes and Dislikes (What things are important for people to understand about you when caring for you?)
Participant Likes:
Participant Dislikes:
Abilities
Mobility
Notes
Aids
Continent
Urine
Yes
No
Faecal
Yes
No
Notes
Aids:
Communication
Aids:
Hearing
Aids:
Vision
Aids:
Cognition
Others
Meal Preferences
A Mealtime plan is prepared
Yes
No
Food Allergies
Food Likes/Dislikes
Special Diet
Notes:
Cultural Considerations
Notes:
Swallowing Difficulty
Yes
No
Notes:
Meal Instructions
Breakfast
Lunch
Dinner
Snacks
Directed Support Plan
Participant Identified Care Needs
Frequency of Service
Agreed Action to be Taken (solutions & strategies identified with the Participant)
Visit Time & Duration
Responsible Person
By When
Contingency and Disaster Plan
Disaster scenario:
Risk level:
Immediate Action plan:
Ongoing support strategy:
Critical equipment:
Emergency contact number:
Participant Files Checklist
Is the intake form Completed?
Yes
No
Individual Risk Assessment Completed?
Yes
No
Home Safety Checklist Completed?
Yes
No
NA
Care Management
Participant and/or nominated representative manages all aspects of Participant Support Plan
Participant and/or nominated representative is consulted on all matters relating to care
Nominated Representative Name and contact information
Support Plan Acceptance
Name
I, _____________________________ has been involved in the development of this support Plan and agree with the goals and services outlined. NBS Health Services has provided me the Participant information booklet with the chapter of Rights and Responsibilities and has explained the content to me. I have given consent for the Support Plan to be shared with people involved in the development of my plan. I consent to NBS Health Services contacting my Medical Practitioner and/or Pharmacy for information about my health care including medications. I consent to NBS Health Services holding a current photo of me on file for use in case of an emergency. I understand and agree that if NBS Health Services has not been advised of any health directive, clinical Support Plan treatment plan or resuscitation order, attending staff are required to follow all normal internal emergency procedures, including the provision of first aid, contacting relevant emergency services and the carer, as well as notification to the relevant office and manager. The honouring of any expectation, plan or clinical order can only take place if NBS Health Services is made aware of the action required for each individual circumstance
Support Plan Start Date
Participant Representative Signature & Name
Date
NBS Health Services Staff Signature, Name & Position
Date
Staff Information
Support Plan Review Date
NBS Health Services Staff
Signature, Name & Position
NBS Health Services Staff
Signature, Name & Position
NBS Health Services Staff
Signature, Name & Position
Date
Date
Date
Participant Orientation Checklist:
Understanding Organizational Processes and Procedures
Participant Orientation Checklist:
This checklist is intended to be reviewed and signed by the participant as an acknowledgment of their comprehension and awareness of our organizational processes and procedures.
Rights and responsibilities
Right to have an advocate of choice
Choose and control service delivery and life decisions
Nurturing cultural, spiritual, and personal identities
Engaging in community participation
Pursuing both short and long-term interests and preferences
Access to interpreters
Complaints and feedback procedures
Participant’s feedback surveys
Incident procedures
Recognising reportable incidents
Charter of Rights
Information about our services, including: • Operating hours and locations • Service details • Points of contact with contact information • Reasons for withdrawal and available supports
Service Access Eligibility Information: • Available resources • Prioritisation processes • Waiting list management • Service refusal and cessation policies • Cost considerations • Transition and exit procedures
Engaging proactively in developing planning strategies
Being informed about a holistic, collaborative, strength-based approach, including strategies for family and caregiver capacity-building
Acknowledging the right to reside in a safe, abuse-free environment
Acknowledgement
I acknowledge that this organisation has provided me with information regarding policies and procedures relevant to my support plan. I am fully aware of my rights and responsibilities during my affiliation with this organisation.
Participant Name:
Date
Participant Signature:
Date
Staff Member
Date
Staff Signature
Date