Wellness Package Returning Client Form First Name Last Name Phone Number Email Do you have a NEW Support Coordinator? Please select an option below Yes No Do you have a NEW Plan Manager? Please select an option below Yes No If either of above are yes please provide more information below Preferred start date for respite Preferred end date for respite Please provide UPDATED & CURRENT information about your NDIS Diagnosis Do any of these Diagnosis apply to you? Psycho-Social Schizophrenia / Schizoaffective Disorder Current / recent Psychosis, Auditory and / or Visual Hallucinations Parkinson's Diagnosis Epilepsy Suicidal Ideation & Self Harm - past or present History of Alcoholism & / or Drug Use Traumatic / Acquired Brain Injury Motor Neuron Disease Advanced Dementia Support Requirements Your support worker is there to: Provide support for any personal care needs you have Provide general transport while you are here Provide transport to & from activities Take you out on day trips so you can explore the local area and all the beauty we have here in Byron Help you navigate the area. As you are not in your familiar environment, knowing where to go, where to eat, where the good beaches are etc can be made a lot easier with a local worker Support you with any extra mobility requirements you have How many hours a day would you like a support worker? Are you coming with your own support worker? Please select an option below Yes No If you're coming with a Support Worker please provide your Support Workers Details (Name/Phone/Email), so we can liaise directly with them about the documentation we require. Or please give them our details and ask them to contact us. Are you coming with friends or family? Please select an option below I'm coming on my own With family or a friend How many bedrooms do you require? I am independent in my daily life Please select an option below Yes No I can easily navigate new experiences Please select an option below Yes No Do you experience fatigue? Please select an option below LOW MED HIGH I experience triggers Please select an option below LOW MED HIGH NONE I experiences anxiety in public spaces and with new people Please select an option below Yes No Mobility Please select an option below LOW - Good to fair mobility (I am able to get up start my day without the use of aids; I can walk short distances) MED - I use mobility aids, occasional wheelchair use HIGH - High risk of falling, multiple falls in the last 6 months, full time wheelchair required, seizures & tremors Have you had any falls in the last 6 months? Please select an option below Yes No Personal Care Please select an option below No support with personal care Some support with personal care (showering & dressing) High support with personal care (showering & dressing and toileting) I require support with food & meal preparation Please select an option below Yes No If I felt unwell, unsafe,or concerned, I could call for help myself Please select an option below Yes No For accommodation purposes are you are a smoker? Please select an option below Yes No Are there any cultural considerations that you would like to share with us What is the biggest take-away from your last respite with us? What are your goals for this new respite? Are there any specifics from your last respite experience that you really valued? Please list any interests and activities that you would like to do during this respite How would you describe your mental health currently? What is your preferred mode of communication? Phone Call Text Email submit