Sleep disturbance ACAT, approved for: Hearing impairment Level 1 Vision impairment Level 2 (please select): insulin tablets diet Level 3 Diabetes, Depressive symptoms 4 Memory problems or confusion Residential Respite Comments: Residential Permanent Placement NDIS Assessment Difficulty communicating Comments: Date Assessed (if known): / / Awaiting assessment Assessment date (if known): – Mental illness, diagnosed? Yes No / / Comments: Comments: Challenging behaviour Comments (please include details of specific triggers Is the care recipient currently receiving any other and behaviour management strategies): services, including services funded by NDIS or a Home Care package?: Allergies No other services Please specify: Commonwealth Home Support Program Home Care Package, Level: Hazards in the home Level 1 Level 2 Please specify: Level 3 4 Indoor smoker(s) NDIS Plan Outdoor smoker(s) Palliative Care Dog(s) Mental Health Services Cat(s) Clinical Mental Health Services Other Pets Other services Please specify: Please provide details about type of assistance, who is Support worker preference, please select: providing it, how often etc. Male Female No preference Please specify any requirements: OTHER SERVICES FOR CARE RECIPIENT: Does the carer or care recipient receive any other Has the care recipient had any assessments? informal supports from family/friends etc? Details: Regional Assessment Team (RAS) Please post completed form to Carers ACT at: 2/80 Beaurepaire Crescent, Holt, 2615 ACT OR scan and it to Phone: 1800 052 222 or (02) 6296 9900
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) Other Pets Please specify: Support worker preference, please select: Male Female No preference Please specify any requirements: OTHER SERVICES FOR CARE RECIPIENT: Has the care recipient had any assessments? Regional Assessment Team (RAS) ACAT, approved for: Level 1 Level 2 Level 3 4 Residential Respite Residential Permanent Placement NDIS Assessment Date Assessed (if known): / / Awaiting assessment – Assessment date (if known): / / Comments: Is the care recipient currently receiving any other services, including services funded by NDIS or a Home Care package?: No other services Commonwealth Home Support Program Home Care Package, Level: Level 1 Level 2 Level 3 4 NDIS Plan Palliative Care 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 care recipient receive any other informal supports from family/friends etc? Details: Please post completed form to Carers ACT at: 2/80 Beaurepaire Crescent, Holt, 2615 ACT OR scan and it to Phone: 1800 052 222 or (02) 6296 9900
Carer-Registration-Form.docx