Shopping Managing finances ALL OF THE ABOVE Does the CLIENT/CARE RECIPIENT have any of the OTHER SERVICES FOR CARER/CLIENT/CARE RECIPIENT: following? Risk of Has the client/care recipient had any assessments? Wandering Aggressive behaviour (verbal) ACAT, approved for: Aggressive behaviour (physical) LOW CARE HIGH CARE Restlessness or agitation Home Care Package: 1 Level 3 Constant supervision required Level 2 Level 4 Emotional support required Regional Assessment Team (RAS) Seizures MAC referral code: Chest pains Service Type: Disorientation NDIS Assessment Sleep disturbance Disability SA Assessment Hearing impairment Vision impairment Date Assessed (if known): / / (please select): insulin tablets diet Awaiting assessment Assessment date (if known): Diabetes, – Depressive symptoms / / Memory problems or confusion Comments: Comments: Difficulty communicating Is the carer or client/care recipient currently receiving Comments: any other services, including services funded by Domiciliary Care, Disability SA, NDIS or a Home Care Mental illness, diagnosed? Yes No package?: Comments: No other services Veterans’ Home Care Challenging behaviour Commonwealth Home Support Service Comments (please include details of specific triggers Home Care Package, and behaviour management strategies): Council Services NDIS Plan Disability SA Allergies Palliative Care Please specify: Community Mental Health Services Clinical Mental Health Services Hazards in the home Other services Please specify: Please provide details about type of assistance, who is providing it, how often etc. Indoor smoker(s) Outdoor smoker(s) Dog(s) Cat(s) Support worker preference, please select: Male worker Does the carer or client/care recipient receive any Female worker other informal supports from family/friends etc? Please specify any requirements: Please post completed form (or drop in) to Carer Support, 770 South Road, Glandore SA 5037 OR scan it, and send it in an email to Phone: 1800 052 222 or (08) 8433 9555 Fax: (08) 8297 4086 Office Use only:
Shopping Managing finances ALL OF THE ABOVE Does the CLIENT/CARE RECIPIENT have any of the following? Risk of Wandering Aggressive behaviour (verbal) Aggressive behaviour (physical) Restlessness or agitation Constant supervision required Emotional support required Seizures Chest pains Disorientation Sleep disturbance Hearing impairment Vision impairment Diabetes, (please select): insulin tablets diet Depressive symptoms Memory problems or confusion Comments: Difficulty communicating Comments: Mental illness, diagnosed? Yes No Comments: Challenging behaviour Comments (please include details of specific triggers and behaviour management strategies): Allergies Please specify: Hazards in the home Please specify: Indoor smoker(s) Outdoor smoker(s) Dog(s) Cat(s) Support worker preference, please select: Male worker Female worker Please specify any requirements: OTHER SERVICES FOR CARER/CLIENT/CARE RECIPIENT: Has the client/care recipient had any assessments? ACAT, approved for: LOW CARE HIGH CARE Home Care Package: 1 Level 3 Level 2 Level 4 Regional Assessment Team (RAS) MAC referral code: Service Type: NDIS Assessment Disability SA Assessment Date Assessed (if known): / / Awaiting assessment – Assessment date (if known): / / Comments: Is the carer or client/care recipient currently receiving any other services, including services funded by Domiciliary Care, Disability SA, NDIS or a Home Care package?: No other services Veterans’ Home Care Commonwealth Home Support Service Home Care Package, Council Services NDIS Plan Disability SA Palliative Care Community Mental Health Services Clinical Mental Health Services Other services Please provide details about type of assistance, who is providing it, how often etc. Does the carer or client/care recipient receive any other informal supports from family/friends etc? Please post completed form (or drop in) to Carer Support, 770 South Road, Glandore SA 5037 OR scan it, and send it in an email to Phone: 1800 052 222 or (08) 8433 9555 Fax: (08) 8297 4086 Office Use only:
registration-form-sept-2018.docx