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About the Participant

Participant Gender Identity*
Is the Participant Aboriginal or Torres Strait Islander?*

Participant Support Needs

Participant Support Needs

What Supports are the Participant Seeking?*

For all remaining support types (this does not include, SIL or MTA) what times would the participant like supports?

Do you need to include public holiday times?*

Participant Transportation Needs

Does the Participant require transport?*

Health and Functional Information

Primary Communication*
Vision*
Hearing*
Mobility*
Self Care (dressing, toileting, eating, bathing, sleeping)*
Do you require complex care supports?*
Please tick all complex care support required below
Does the Participant require any invasive procedures - Please select any that apply below:*

Allergies

Does the Participant have any allergies?*

Medications

Does the participant require support with medication management?*

Diet / Nutrition

Behaviours

Select the risk factors that SCSS needs to be aware of for this assessment:*
Does the participant have a current Positive Behaviour Support Plan (PBSP)?*

Restrictive Practices

Does the Participant have current restrictive practices in place?*
Please tick all that apply below:

Participant Plan Details

Does the Participant have a Support Coordinator?*
Plan Date Start*
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Plan Date Finish*
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Referrer’s Details