Boorn NDIS About Me VSF1.1

About Me and My Supports- Enrolment form

Participant Details

Title

First Name *

Last Name *

Address

How Did you hear about us? *

Participant Email Address *

Phone *

Gender

FemaleMale Non-Binary Other

Date of Birth *

Plan Start Date

Plan End Date

UPLOAD NDIS PLAN *

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NDIS Number *

Plan Management ONLY: Who are you currently engaged with for services? Frequency? Amount? Do you have a service agreement?

Alternative Contact (Next of Kin/Carer/Plan Nominee)

Alternative Contact Name *

Relationship *

Alternative Contact Phone *

Alternative Contact Email *

Advocate Information (where required)

Advocate Name

Advocate Relationship

Advocate Phone

Advocate Email

Formal Decision Maker (where required)

Decision Makers Name

Decision Makers Relationship

Decision Makers Phone

Decision Makers Email

My Communication and Language

My Preferred Language *

I require an interpreter *

YesNo

I require assistance to communicate *

Yes No

Details

How to communicate with me in an emergency

My cultural identity and spiritual beliefs

People who are important to me

My Living Arrangements (who I live with in what type of setting)

How I spend my day?

My Likes and Interests

My Dislikes

De-escalation Strategies: *

Challenging Behavior / Triggers? *

Document Upload - If Applicable ( eg Diagnoses, school reports, other )

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Document upload - Extra (Any more please email Grow@BOORN.Family )

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My Supports

What is important to me in the supports I receive from BOORN?

My Ideal team member would be (e.g., male/female, age, interests)

Do you have any Allergies or Medical Conditions our staff need to be aware of? *

YesNo

Allergies/ Medical Condition Details

Primary and Secondary Disability

I have a Behaviour Support Plan *

Yes- Please provide your Behaviour Support Plan developed by a NDIS Behaviour Support PractitionerNo

I require assistance with my medication

Yes- please provide a medication schedule from your prescribing practitioner that is dated no longer than three months old.No

Other information I would like to share? Please include any unsafe behaviours.

Emergency Contacts (people I can rely on in an emergency)

Emergency Contact 1 Name *

Emergency Contact 1 Phone *

Emergency Contact 1 Email *

Emergency Contact 1 Relationship *

Emergency Contact 2 Name

Emergency Contact 2 Phone

Emergency Contact 2 Email

Emergency Contact 2 Relationship

If there was an emergency or disaster, how would you like us to support you?

My Important Contacts and Services

Advocate

Childcare/ School Contact

Power of Attorney/ Guardian

WorkPlace/ Volunteer Contact

Solicitor

Doctor

My Formal Support People's Name and Role

My Formal Support People's Organisation

My Formal Support People's Phone

My Formal Support People's Email

Emergency Contacts *

I/my support network have access to a phone, computer, or tablet to be able to stay in touch with people or call people in an emergency I/my support network have enough data and credit to keep in touch

BOORN Organisation emergency and disaster management plan

Covid-19 outbreak and lockdowns

Where a confirmed case BOORN will explain to you the need to isolate and explore options with you.

If there is a Covid-19 lockdown issued by the state government BOORN will contiue to provide essential services in accordance with health advice and government mandates

BOORN will continue to provide services that you are dependent on for daily living with appropriate infection control management

Participants and their families will not be able to attend the centre in person where they are demonstrating symptoms of BOORN, telehealth appointments will be offered where appropriate.

Fire

Team member will not travel into fire zones, in this case, Emergency Services and Emergency Contact lists will be activated by BOORN, who will monitor your safety through ongoing communication with you and your supports.

If a BOORN centre is under threat of bushfire the centre will close and appointments will be rescheduled.

Flood

Team members will not travel into floodwaters, in this case BOORN will contact you to assess the situation, contact your local Emergency Services secondary contacts as required. Team members will provide ongoing communication to monitor your safety.

If a BOORN centre or surrounding areas are affected by floodwaters, the centre will close and appointments will be rescheduled or offered by telehealth where appropriate.

Extreme Heatwaves

BOORN representatives will contact with you prior to the heatwave (weather forecast) to ensure adequate cooling, water and other requirements are available. If required, BOORN will either provide, or contact your Support Network for availability of onsite support.

Thunderstorms and severe weather

A BOORN representative will contact you prior to the event (weather forecast) to ensure food, water, and other requirements are available. If required, BOORN will either provide onsite support or contact your Support Network for the availability of onsite support.

If thunderstorms or servere weather cause poweroutages, or it is deemed unsafe for participants to travel to the centre, the centre will close and appointments will be rescheduled.

Data breach

Review impact of the data breach

Advise you of the breach

Advise the AOIC where it may cause serious harm to you https://www.oaic.gov.au/privacy/notifiable-data-breaches/report-a-data-breach

Undertake remedial action

I give consent for BOORN to contact the emergency contact people/services listed on this plan in the event of an emergency. (Participant or Guardian/Caregiver) *

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My Safety Assessment

Consideration should be made regarding the participant and their family unit/ support network (Tick all that are relevant) *

Is the participant living alone and has high care needs or is living with an individual with similar or greater needs?Does the participant experience challenges in making an independent decision due to cognitive or other impairment?Is the participant likely to experience difficulty in making contact in the event of an emergency (e.g., has limited / unreliable phone service or is hearing impaired etc.)?In the event of a disaster or emergency, to what extent is the participant reliant on the supports provided by BOORN for their daily needs?In case of an emergency and the participant reprehensive is unable to care for the participant, is someone able to take on this reasonability on? not required

What are the likely effects to the participants health and wellbeing if services were disrupted due to natural disaster or emergency?

My Goals and Risk Assessment

My First Goal: Think about what is important to you and the life you would like to live. *

Date I would like to achieve this goal: *

How will I achieve this goal? *

Are there any barriers to achieving the goal? *

What will assist me in achieving this goal? *

My Longer Term Goals and Aspirations *

What are your dislikes: ( As we ask the participant if old enough to communicate )

What are your Likes: ( As we ask the participant if old enough to communicate )

What are your Goals: ( As we ask the participant if old enough to communicate )

Individual Risk Assessment

(Only complete those areas related to the services to be provided to the participant and ensure you address potential risks and put in place risk controls.)

Incase of an emergency and the participant reprehensive is unable to care for the participant, who is able to take this on? *

Communication

Hearing ImpairmentSpeech ImpairmentAble to WriteLinguistically Diverse

Cognition

Oriented in time and placeResponsive to direction and instructionShort-term memory loss

Managment Strategies for Identified Risks

I acknowledge that the information recorded here is a true and accurate representation at time of submission. Participant or Guardian/Caregiver *

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