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Wellness Package Enquiry Form
First Name
Last Name
Date Of Birth
Phone Number
Email
Post Code
How is your plan managed?
Please select an option below
Self
Plan
Agency
Plan Manager
NDIS No.
Preferred start date for respite
Preferred end date for respite
Please provide detailed 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
Support Coordinator Name
Support Coordinator Company Name
Support Coordinator Number
Support Coordinator Email
Please pick from the list below:
Please select an option below
I require flights
I need a pick up service as I am within driving distance
I am getting myself there
What is your ultimate goal from your respite?
Please list any interests and activities that you would like to do during your respite
Anything else we need to know to support you during your respite?
What is your preferred mode of communication?
Phone Call
Text
Email
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