Referral form - Omega Support

Step 1 of 11

Name

First Last

Date

MM slash DD slash YYYY

Preferred name

Date

MM slash DD slash YYYY

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Contact

How does the person communicate?

Verbal

Assistive tech

Auslan

Other

Language/s

Interpreter required?

Yes

Preferred method of contact

Mobile

SMS

Post

Who will give referral consent?

Participant

Family/ Carer

Guardian

Primary disability/ diagnosis

Other notes

Is there a family member or advocate to support the person?

Yes (If yes, please provide contact details below)

Is there a current/active guardianship order?

Yes

Nominated Support Person 2

Advocate

Guardian

Family member

Friend

Emergency contact

Plan nominee

Name

First Last

Phone

Nominated Support Person 1

Advocate

Guardian

Family member

Friend

Emergency contact

Plan nominee

Name

First Last

Phone

Please briefly describe the reason for referral and the services you are seeking from Omega

Preferred times for support

Overnight

This information is only an initial guide

Preferred days

Monday

Tuesday

Wednesday

Thursday

Friday

Weekends

Is there a preferred date for commencement of services?

Yes

N/A

Worker preference

Gender

Skills

Interests

Other

Cultural requirements

NDIS number

Plan start date

MM slash DD slash YYYY

Plan end date

MM slash DD slash YYYY

How is the plan managed?

NDIA Managed

Plan managed

Self-managed

NDIS goal 1

NDIS goal 2

NDIS goal 3

Consent to share NDIS plan with Omega?

Yes

NDIS funding to be allocated

indicate hours or amount

NDIS funding to be allocated

indicate hours or amount

Plan Manager Details

Phone

Daily Living Skills

Does the person require assistance with personal care?

Yes

Bathing/ showering

Full assistance

Some assistance

Prompt/ supervision

Not required

Dressing

Full assistance

Some assistance

Prompt/ supervision

Not required

Teeth cleaning

Full assistance

Some assistance

Prompt/ supervision

Not required

Shaving

Full assistance

Some assistance

Prompt/ supervision

Not required

Continence aids

Full assistance

Some assistance

Prompt/ supervision

Not required

Accessing toilet

Full assistance

Some assistance

Prompt/ supervision

Not required

Does the person require assistance to complete household tasks?

Yes

Light cleaning

Full assistance

Some assistance

Prompt/ supervision

Not required

Making bed

Full assistance

Some assistance

Prompt/ supervision

Not required

Laundry

Full assistance

Some assistance

Prompt/ supervision

Not required

Menu planning

Full assistance

Some assistance

Prompt/ supervision

Not required

Folding clothes

Full assistance

Some assistance

Prompt/ supervision

Not required

Grocery shopping

Full assistance

Some assistance

Prompt/ supervision

Not required

Meal preparation

Full assistance

Some assistance

Prompt/ supervision

Not required

Does the person use equipment for mobility?

Yes

Walking stick

Full assistance

Some assistance

Prompt/ supervision

Not required

Walking frame

Full assistance

Some assistance

Prompt/ supervision

Not required

Wheelchair (manual)

Full assistance

Some assistance

Prompt/ supervision

Not required

Wheelchair (powered)

Full assistance

Some assistance

Prompt/ supervision

Not required

Hoist transfer

Full assistance

Some assistance

Prompt/ supervision

Not required

Hoist transfer

Full assistance

Some assistance

Prompt/ supervision

Not required

Health

Does the person have health support needs?

Yes

Select any relevant conditions

Epilepsy

Diabetes

Asthma

Allergies (please detail in space below)

Catheter

Bowel care

Other (please detail in space below)

more detail

Do staff require specific training?

Yes

Does the person need assistance to manage medication?

Yes

Does the person require a modified diet?

Yes

Does the person experience swallowing difficulties?

Yes

Is there a current mealtime profile/ mealtime management plan?

Yes

Behaviour Support

Does the person display behaviour that could pose a risk to themselves or others

Yes

Is there a current Behaviour Support Plan?

Yes

If yes, date plan was last reviewed:

Has the person ever been, or are they currently involved with the forensic/ legal/ criminal justice system?

Yes

If yes, please provide further detail:

Is the person subject to current charges, bail conditions, court order, VCAT order (eg: IVO, NCSO, Community Corrections order etc.)

Yes

If yes, please provide further detail:

Initial Risk Screening

Type of residence

House

Unit

Disability Residential Service

Aged Care Facility

SRS

Caravan Park

Other

Access to property

Does the participant live alone?

Yes

If no, who else resides at the property?

Comment

Is property number visible from the street?

Yes

Comment

Is off street parking available?

Yes

Comment

Is there adequate external lighting?

Yes

Comment

Are there seasonal risks? eg: is the property in a bushfire prone area

Yes

Comment

Are there animals kept at the property? If yes, can they be secured away from staff

Yes

Comment

Are weapons known to be kept on the property?

Yes

Comment

Is it likely anyone will be smoking or drinking alcohol when staff are present?

Yes

Comment

Is there known substance use by any person who may be present?

Yes

Comment

Does any other occupant have a history of aggressive behaviour?

Yes

Comment

Is there anything at the property that could make it unsafe for workers to visit?

Yes

Comment

Attachment List

Please provide available assessments, reports, plans

NDIS plan or copy of plan budget

Attached

Comment

Behaviour support plan

Attached

Comment

Risk assessment

Attached

Comment

Manual handling profile

Attached

Comment

Mealtime profile

Attached

Comment

Court orders

Attached

Comment

Mental health plan/recovery plan

Attached

Comment

Allied health assessments

Attached

Comment

Asthma management plan

Attached

Comment

Diabetes management plan

Attached

Comment

Medication authority

Attached

Comment

Other

Attached

Comment

Referrer name

Relationship

Organisation

Phone

Privacy Statement/ Personal Information

Personal information collected will be retained and used for the purpose of assessment, planning and to provide your services. We will not disclose or share your personal information without prior written consent. To access or seek correction of your personal information please contact us 1300 160 13