NDIS Participant Support Plan

Participant Support Plan

SUPPORTS

Support

Description

How the support will be provided

Add another support

Support

Description

How the support will be provided

Add another support

Support

Description

How the support will be provided

PARTICIPANT DETAILS

Participant’s First Name *

Participant's Last Name *

Date of Birth *

Address

Postcode

Phone

Cultural Background and Preferences

Preferred Language

EMERGENCY INFORMATION

Emergency Contact 1

Name

Phone/Email

Relationship

Emergency Contact 2

Name

Phone/Email

Relationship

Does the participant require assistance in an emergency?

YesNo

Please provide details

HEALTH AND MEDICAL INFORMATION

Allergies / Alerts

Disability and / or Medical Conditions

GP Details

Name

Practice

Phone/Email

Pharmacist Details

Name

Practice

Phone/Email

Medication

Medication Required

YesNo

Prompt Required

YesNo

Assistance Required

YesNo

Administration Required

YesNo

DetailsSupport Plans must include clear instructions, agreed with the participant, about what steps staff will take to help the participant with their medication.

SCHEDULE OF SUPPORT

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Sunday

RISK

Risk Summary

Outline any potential risks identified and strategies to mitigate them.

Description of Risk

Risk Level

HighMedLow

Action

Add another risk

Description of Risk

Risk Level

HighMedLow

Action

Please upload a copy of any additional Risk Assessment material

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SUPPORT PLAN AGREEMENT

Signatures

By signing this Support Plan, I agree that I have been involved in the development of my plan of care, my goals and the services required. *

Participant/Representative Signature *

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Participant/Representative Name *

Date *

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