PERSON CENTRED CARE PLEASE INSERT CURRENT PHOTO HERE NAME: ADDRESS POST CODE: PHONE: MOBILE: Country of origin (birth):

Transcription

1 PERSON CENTRED CARE PLEASE INSERT CURRENT PHOTO HERE NAME: DATE OF BIRTH / / MALE FEMALE ADDRESS POST CODE: PHONE: MOBILE: DATE FORM WAS COMPLETED: Country of origin (birth): Language(s) spoken at home: Is a translator required? yes no

2 Is the child of aboriginal or Torres Strait islander descent? yes no Does the child have specific cultural requirements? yes no If yes, provide details Is the child a registered client with Intellectual Disability Services (DHHS) If you currently have a Case Manager, please provide their details; Case Managers name: Phone: The organisation your case manager works for: Do you receive individualised funding? Please provide details. PARENT / GUARDIAN DETAILS. Name: Relationship: Day time phone: Mobile: Name: Relationship: Day time phone: Mobile: EMERGENCY CONTACT (if PARENT / GUARDIAN cannot be contacted) 1. Name: Relationship: Address: Phone: Mobile: 2. Name: Relationship: Address: Phone: Mobile: 3. Name: Relationship: Address: Phone: Mobile:

3 COURT ORDERS. Are any current court orders pertaining to your child? If yes, please attach a copy. Concession Card no: SCHOOL DETAILS: NAME OF SCHOOL: ADDRESS: PHONE NUMBER MEDICAL INFORMATION. Name of treating Doctor: Address: Phone number: Name & type of specialist: Address: Phone number: Medicare number: Private Health Cover: Ambulance Subscription: What other diagnosis does your child have? (e.g. Intellectual disability, Down Syndrome, ADHD) Does your child suffer from any of the following conditions? (circle relevant conditions). ASTHMA EPILEPSY DIABETES PSYCHIATRIC ILLNESS ALLERGIES Provide treatment/management strategies or attach specific health management plans

4 Does your child take any regular medication? If yes please complete attached Client Treatment Sheet Does your child have a PRN/emergency dose of any medication prescribed? Yes No If yes please complete attached Client Treatment Sheet What immunizations has your child received? Hepatitis B Chicken Pox Triple Antigen Measles/Mumps/Rubella Meningococcal C Tetanus date: / / Other: MOBILITY TRANSFERS SHOWER WHEELCHAIR TOILET OTHER

5 HEARING & VISION Additional information: ABOUT ME! WHAT IS IMPORTANT TO ME? The people most important to me are (family, friends etc): My brothers and sisters are: The people who know me best are: I spend most of my time with: Some great things about me are:

6 Things other people like about me are: Some things I like to do: at home are: At school are: At respite are: For fun I like to: Some things that are important to me are: Things which make me happy are: Some things which frighten or upset me are: When frightened or upset I may behave in the following way:

7 You can help me when I m frightened or upset by: I can become fixated by some things, they are: If necessary, I can be distracted by: MY SAFETY ISSUES When travelling in a vehicle I may (take seatbelt off, bang windows, etc): On the bus I like to sit (where?): My sense of road safety is: Am I likely to abscond from carers? Am I likely to abscond from a house/centre? Staff will need to hold my hand on outings. Are there any other safety measures staff must take when working with you? Please provide full clear details.

8 MY COMMUNICATION I communicate best by (verbal, non-verbal, picture exchange, sign, etc): Staff can assist my communication by: (using single words, simple clear sentences, using pictures or actual objects): Some words, phrases or actions I use may need explanation for staff working with me. Words, phrases or actions which need explanation are: Some things I like to talk about are: Some things to avoid talking about are: MY EATING & SLEEPING PATTERNS My favourite foods are: My favourite drinks are:

9 Food and drink I dislike are: I cannot eat some foods, these are: My diet is restricted due to allergies. I can feed myself independently. I would like staff to help with my meals by: My preferred foods for each meal are: Breakfast: Lunch: Dinner: Snacks: For school or excursion lunches I prefer: I usually sleep through the night? I like the bedroom light.. On Off I like the bedroom door left Open Closed

10 Some strategies which may help me to settle at bedtime, or if I wake during the night include: The time I usually go to bed is: The time I usually get out of bed is: TOILETING & HYGIENE Please tick the box(es) which best describe your toileting ability. I wear nappies all the time I wear nappies only at night Please take me to the toilet frequently I will let you know when I need to go, but require assistance I will need your supervision I am fully independent I will use a public toilet. I am frightened by hand driers in public toilets. My preference for bathing is: Bath Morning Shower Evening I can wash my own hair. I have difficulty with someone else washing my hair. I can brush my own hair. I have difficulty with someone else brushing my hair. I can brush my own teeth.

11 I have difficulty with someone else brushing my teeth. I am learning how to do some things and would like staff to help me learn the following: Describe any other assistance you may require with personal care tasks. I am able to do the following tasks without assistance: INDEPENDENT SKILLS. I am learning how to do the following things but will need some staff assistance. Please list the skills you would like some help with and describe how staff should provide this help. Skill: Describe assistance needed: Skill: Describe assistance needed: Skill: Describe assistance needed:

12 Skill: Describe assistance needed: ACTIVITIES I LIKE Swimming TV/videos Trampoline Walking Books Music Drawing Playgrounds Other: Excursions I enjoy are: Excursions I dislike are: Are you involved in any recreation groups? Please give details.

13 Please add any information you believe will help staff to make your time at Nepean Centre more enjoyable.