Disability care Booking Form What support do you need?NDIS CleaningCare SupportFirst Name *Last Name *Email Address *Date of Birth *Phone *My current living situation is *Choose an OptionOwn HomeRenting a House/ApartmentLiving with familyLiving with friendsBoarding houseResidential Care FacilityAre you currently receiving any other forms of care or support? *Choose an OptionYesNoMy current financial situation regarding government funding *Choose an OptionI am receiving government-funded disability servicesI am not receiving government-funded disability servicesI am not sureI require support with *Mobility impairments (e.g. paralysis)Vision impairments (e.g. blindness or low vision)Hearing impairments (e.g. deafness or hard of hearing)Cognitive impairments (e.g. intellectual disabilities or learning disabilities)Mental health conditions (e.g. anxiety disorders)Autism spectrum disordersChronic illnesses (e.g. multiple sclerosis)Neurological conditions (e.g. epilepsy)Speech and language impairmentsTraumatic brain injuries (TBI)I require support with *Personal care including assistance with bathing/ grooming and dressingMobility assistance including help with transferring/ using mobility aids and navigating the homeMedication management including reminders/administration and monitoringHealth monitoring including checking vital signs and observing symptomsMeal preparation including planning and cooking meals that meet dietary restrictions and preferencesTransportation including help with getting to appointments/running errands and participating in social activitiesHousehold tasks including cleaning/laundry and organisationEmotional support including companionship and socializationAssistance with communication including sign language interpretation or augmentative and alternative communication (AAC) devicesSupport with accessing education/employment and community resourcesMy long term goals for care & support are *Increase independenceImprove physical health and well-beingManage and reduce painImprove mental health and emotional well-beingIncrease social connections and community participationDevelop and achieve personal goalsImprove quality of lifeEnhance skills for daily livingMaintain current level of functioningPrepare for future changes in care needsPlease consider my specific religious or dietary needs as follows *HalalKosherVegetarianVeganGluten-FreeDairy-FreeNut-FreeLow-SugarLow-SodiumMy preferred methods of communication are *Choose an OptionPhone CallEmailText MessageVideo CallIn-Person MeetingI declare that the info I've provided is accurate and completeBook Now
