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25 Palmerston Street Melton, Vic
info@patacommunitycare.com.au
Empowering you,
will empower us.
+61410273349
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Psychosocial Recovery
Hospital Discharge
Short Term Accommodation (STA)
Blog
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Menu
Home
About Us
Services
NDIS Core Support
Yard Maintenance
Household Support
Respite Care
Social Skills Development
Transport Assistance
Social and Community Participation
Capability Building Supports
Disability Support
Supported Independent Living
Psychosocial Recovery
Hospital Discharge
Short Term Accommodation (STA)
Blog
Contact Us
Home
About Us
Services
NDIS Core Support
Yard Maintenance
Household Support
Respite Care
Social Skills Development
Transport Assistance
Social and Community Participation
Capability Building Supports
Disability Support
Supported Independent Living
Psychosocial Recovery
Hospital Discharge
Short Term Accommodation (STA)
Blog
Contact Us
Menu
Home
About Us
Services
NDIS Core Support
Yard Maintenance
Household Support
Respite Care
Social Skills Development
Transport Assistance
Social and Community Participation
Capability Building Supports
Disability Support
Supported Independent Living
Psychosocial Recovery
Hospital Discharge
Short Term Accommodation (STA)
Blog
Contact Us
MAKE A REFERRAL
Home
About Us
Services
NDIS Core Support
Yard Maintenance
Household Support
Respite Care
Social Skills Development
Transport Assistance
Social and Community Participation
Capability Building Supports
Disability Support
Supported Independent Living
Psychosocial Recovery
Hospital Discharge
Short Term Accommodation (STA)
Blog
Contact Us
Menu
Home
About Us
Services
NDIS Core Support
Yard Maintenance
Household Support
Respite Care
Social Skills Development
Transport Assistance
Social and Community Participation
Capability Building Supports
Disability Support
Supported Independent Living
Psychosocial Recovery
Hospital Discharge
Short Term Accommodation (STA)
Blog
Contact Us
MAKE A REFERRAL
We Take Your Referral Very Seriously
Participant Referral Support Plan
This Plan will Consist of:
1. Personal Information
2. Health and Medical
3. Safety Assessment Personal
Services Requested
Select
NDIS Core Support
Capability Building Supports
NDIS Therapeutic Supports
Supported Independent Living
Support Coordination
Psychosocial Recovery
Hospital Discharge
Short Term Accommodation (STA)
Specialised Disability Accommodation (SDA)
- NDIS Core Support
Select
Yard Maintenance
Household Support
Respite Care
Social Skill Development
Transport Assistance
Social & Community Participation
- Capability Building Supports
Select
Disability Support
- NDIS Therapeutic Supports
Select
- Couselling
- Physiotherapy
- Occupational Therapy
- Speech Pathology
NDIS Number
First Name
Last Name
Date of Birth
Phone Number
Email
Street Address
City
State / Province
Postal / Zip Code
Language
Select
Afghan
Albanian
Algerian
American
Andorran
Angolan
Antiguans
Argentinean
Armenian
Australian
Austrian
Azerbaijani
Bahamian
Bahraini
Bangladeshi
Barbadian
Barbudans
Batswana
Belarusian
Belgian
Belizean
Beninese
Bhutanese
Bolivian
Bosnian
Brazilian
British
Bruneian
Bulgarian
Burkinabe
Burmese
Burundian
Cambodian
Cameroonian
Canadian
Cape verdean
Central african
Chadian
Chilean
Chinese
Colombian
Comoran
Congolese
Costa rican
Croatian
Cuban
Cypriot
Czech
Danish
Djibouti
Dominican
Dutch
East timorese
Ecuadorean
Egyptian
Emirian
Equatorial guinean
Eritrean
Estonian
Ethiopian
Fijian
Filipino
Finnish
French
Gabonese
Gambian
Georgian
German
Ghanaian
Greek
Grenadian
Guatemalan
Guinea-bissauan
Guinean
Guyanese
Haitian
Herzegovinian
Honduran
Hungarian
Icelander
Indian
Indonesian
Iranian
Iraqi
Irish
Israeli
Italian
Ivorian
Jamaican
Japanese
Jordanian
Kazakhstani
Kenyan
Kittian and nevisian
Kuwaiti
Kyrgyz
Laotian
Latvian
Lebanese
Liberian
Libyan
Liechtensteiner
Lithuanian
Luxembourger
Macedonian
Malagasy
Malawian
Malaysian
Maldivan
Malian
Maltese
Marshallese
Mauritanian
Mauritian
Mexican
Micronesian
Moldovan
Monacan
Mongolian
Moroccan
Mosotho
Motswana
Mozambican
Namibian
Nauruan
Nepalese
New zealander
Ni-vanuatu
Nicaraguan
Nigerien
North korean
Northern irish
Norwegian
Omani
Pakistani
Palauan
Panamanian
Papua new guinean
Paraguayan
Peruvian
Polish
Portuguese
Qatari
Romanian
Russian
Rwandan
Saint lucian
Salvadoran
Samoan
San marinese
Sao tomean
Saudi
Scottish
Senegalese
Serbian
Seychellois
Sierra leonean
Singaporean
Slovakian
Slovenian
Solomon islander
Somali
South african
South korean
Spanish
Sri lankan
Sudanese
Surinamer
Swazi
Swedish
Swiss
Syrian
Taiwanese
Tajik
Tanzanian
Thai
Togolese
Tongan
Trinidadian or tobagonian
Tunisian
Turkish
Tuvaluan
Ugandan
Ukrainian
Uruguayan
Uzbekistani
Venezuelan
Vietnamese
Welsh
Yemenite
Zambian
Zimbabwean
Interpreter Required
Select
Yes
No
Participant Identify as
Select
LGBTIQA+
Aboriginal
Aboriginal and Torres Strait Islander
CALD
Torres Strait Islander
Normal People
Interpreter
Select
Auslan
TTL
Assistive Technology
Binary
Normal People
Guardian Details
First Name
Last Name
Relationship with Participant
Phone Number
Email
NDIS Plan Start Date
NDIS Plan End Date
Plan Manager First Name
Plan Manager Last Name
Plan Manager Email
Does the Participant Live Alone?
Yes
No
Is the Participant Supported by only one Worker?
Yes
No
Support Coordinator
First Name
Last Name
Email
Phone Number
Emergency Contact
First Name
Last Name
Phone Number
First Name
Last Name
Phone Number
Medium - Term Goal
Short - Term Goal
Long - Term Goal
Allergies / Alerts
Primary Disability
Secondary Health / Medical Conditions
Is the Client at Risk of Choking, Seizures or Anaphyxalis
Yes
No
Is assist with Medication Administration Required
Yes
No
Does Client Suffer from Irritants, Phobias or any other Specific Condition
Yes
No
Do you give consent to share this form with your Support Network, other providers. and Relevant Government Agencies?
Yes
No
Describe the Support Required
Is this Home easy to Locate?
Yes
No
Is Onsite / Street Parking Available for Support Worker's Car
Yes
No
Are any Gates or Doorways Difficult to use or Access
Yes
No
At night, is the House Entrance Hard to Find
Yes
No
Are there any Slip, Trip or Failing Hazards Outside the Home
Yes
No
Is the Home Wheelchair Accessible
Yes
No
Will the Support Worker be required to use any Electric Appliances
Yes
No
In case of any emergency in the home, please describe the emergency procedure for the support worker to follow. Please consider any special procedures, nearest exits and emergency meeting points
Is there anything else you would like to share about the home
NOTE:
It is the participant's responsibility to ensure certain safety requirements
Electrical appliances and power cords are in good working order.
Power cords are attached to power boards and power sockets, and not double adapters
The house is fitted with a safety switch
Support workers will not be exposed to cigarette smoke in the home
Are there any places, situations or specific irritants that should be avoided
Please provide details on how to manage this risk. Describe in detail if there is any way to avoid
If something goes wrong in the community, are there any specific emergency instructions for the support worker
Is there a risk that participant may abscond
Yes
No
What type of transport participant will use? Please tick the relevant.
Select
Public Transportation
Using the Participant's Car (with the support worker driving)
Using the Support Worker's Car
Are there any specific risks associated with transport
Are there any specific risks associated with transport
Do you give consent for the support worker to proactively support you in attending medical, and allied health services?
Yes
No
PATA Community Care will take reasonable efforts to work with the participant in selecting the preferred support worker
Date / Time
Send