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Your First name
*
Your Last name
*
Your Email
*
Your home phone number
Your mobile phone number
*
ABOUT THE PARTICIPANT
Please enter the details of the person who will be staying at Summer Hill House
.
Participant First Name
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Participant Last Name
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Participant Date of Birth
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Day
/
Month
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Year
Gender
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Female
Male
Other
Does the participant have a current NDIS plan?
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Yes
No
Mobility – Walking and assistance requirements
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Please Select
The client can walk without assistance
The client can walk but requires assistance from a person or walking frame
Participant uses a wheelchair but can move independently
Participant uses a wheelchair but cannot move independently and requires full assistance
Mobility – Transferring and assistance requirements
*
Please Select
Participant can move from bed to chair without assistance
Participant not able to move from bed to chair and requires support from hoist and sling
Participant requires some assistance to move from bed to chair
Does the participant require assistance with self-care
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No
Yes
Does the participant have any behaviours of concern?
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No
Yes
Nutrition – Does the participant eat and drink orally?
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Yes
No
If you selected "Yes" to nutrition, please select all that apply
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No modification to diet
Modified meal
Thickened fluids
Fluids via gastrostomy
Nutrition via gastrostomy
Booking Dates
Preferred check-in date?
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Day
/
Month
/
Year
Preferred check-out date?
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Day
/
Month
/
Year
Is there anything else we should know?
Are there any other services you’re interested in?
Supported Independent Living
Short Term Accommodation and Respite
Day Programs
Drop-in Support
Community Based Support
Health and Wellbeing
Disability Employment
Support Coordination
Other
How did you hear about us?
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Please Select
Allied Health Professional
Driving past
Event/Expo
Existing Customer
Friend/Family
Google search
Housing Platform (Housing Hub/GoNest or others)
Newspaper
Social media
Support Coordinator
Word of mouth
Others
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