Medical Form

The questions on this form allow us to support you safely during your respite & to ensure we have the right care and support in place for you.

First Name

Last Name

Street Address

City

State

Post Code

Emergency Contact Name

Emergency Contact Number

Please provide a summary of your (i) Medical Diagnosis and (ii) History

Please list any medications you are taking and what they are for:

Do you have any allergies? Please list:

Are there any recent addictions that are currently impacting your mental health?

How would you describe your current emotional state. Please choose what you experience from the following list:

Other - Please describe:

Are you pregnant?

Yes No

Emergency Plan

What is a Personal Emergency Plan?
An action plan with clear procedures in place for escalations and emergencies outside of requiring an immediate 000 response.

Why do we ask for this?
To ensure your health, safety & wellbeing in case of an escalation or emergency.

Please complete the question below to ensure we know how you prefer to be supported if an escalated situation were to arise.

A. Please list areas of concern that relate to your health, safety & wellbeing.
B. What is your preferred method of support/intervention?

Area of safety concern