QF107 Review Checklist - LAAS | Lifestyle Assistance & Accommodation Service

(08) 7547 9111

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Lifestyle Assistance & Accommodation Services
Disability Services in the Riverland and Mallee Region
Office: 39 East Terrace, Loxton. SA 5333
Post: PO Box 1019, Loxton SA 5333
08 7547 9111

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Customer Name:
Date of Review:
DD slash MM slash YYYY
Address:
Living Arrangements:
Mobile:
Home:
Email
DOB:
DD slash MM slash YYYY
Culture/Religion:
Primary Disability:
Informal/formal Carer:
Other Service Provider Contact Details:
Funding Body:
Region/Unit:
Region/Unit:
Phone:
Email:
Type of Service/s:
Service Codes:

PC= Personal care- assistance with self-care tasks

D= Domestic assistance- assistance with house chores assistance

HM= House maintenance (e.g. lawn mowing)

T= Transport

W= Work

M= Medication

C= Continence care

CA= Community access
Type of Equipment Used:
Next of Kin:
Relationship:
Address:
Phone:
Are you happy with the services you are currently receiving or would you like them to change in some way?
Do these services meet your current needs?
Do you need more support managing your roster and personal attendants?
What qualities make a good personal attendant for you?
Do you have any personal goals you would like support with?
Do you have any strategies or ideas how you could reach these goals?
Do you participate in any type of community involvement?
Type
When/how often
Address/Contact Details
Type
When/how often
Address/Contact Details
Type
When/how often
Address/Contact Details
If not would you like too?
How can we support you to becoming more involved with the community?
Is there anything else we can support you with?
My Rostered Supports

This roster is to estimate my usage in hours for the financial year. These hours may be flexible and accumulative over a period of time (refer to funding contract).
- WEEK 1
- Sunday
- Monday
- Tuesday
- Wednesday
- Thursday
- Friday
- Saturday
- MORNING- (after 6am)
- Sunday Morning
- Monday Morning
- Tuesday Morning
- Wednesday Morning
- Thursday Morning
- Friday Morning
- Saturday Morning
- AFTERNOON
- Sunday Afternoon
- Monday Afternoon
- Tuesday Afternoon
- Wednesday Afternoon
- Thursday Afternoon
- Friday Afternoon
- Saturday Afternoon
- NIGHT- (after 9pm)
- Sunday Night
- Monday Night
- Tuesday Night
- Wednesday Night
- Thursday Night
- Friday Night
- Saturday Night
- WEEK 2
- Sunday
- Monday
- Tuesday
- Wednesday
- Thursday
- Friday
- Saturday
- MORNING- (after 6am)
- Sunday Morning
- Monday Morning
- Tuesday Morning
- Wednesday Morning
- Thursday Morning
- Friday Morning
- Saturday Morning
- AFTERNOON
- Sunday Afternoon
- Monday Afternoon
- Tuesday Afternoon
- Wednesday Afternoon
- Thursday Afternoon
- Friday Afternoon
- Saturday Afternoon
- NIGHT- (after 9pm)
- Sunday Night
- Monday Night
- Tuesday Night
- Wednesday Night
- Thursday Night
- Friday Night
- Saturday Night
Morning Services:
Afternoon Services:
Afternoon Services:
Afternoon Description:
Night Services:
Night Description:
Funding Allocation:
Hours:
Description:
Rostered Hours:
How often would you like your review with your service provider?
- 3months
- 6months
- 12months

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