LAAS | Lifestyle Assistance & Accommodation Service

QF306 Individual Support Plan


Name
Ambulance Cover
Entry to home
No response process
Key safe
number
Transport
Allergies/reactions
COMMUNITY SUPPORT CONTACTS
Current Community Support Services Name of Contact Phone
MEDICAL CONTACTS (GP, SPECIALIST, PSYCHOLOGIST ETC)
Medical Professional's Name Address Phone
Pharmacy Contact Address Phone
A LITTLE BIT ABOUT ME AND MY DISABILITY
MY MEDICAL HISTORY

Is there a medical consent in place?

Is there an advanced care directive in place?

Copy provided

MEDICAL CONSENT
Name Start Date End Date Contact Details
MY MEDICATIONS
(i.e. state if you have any PRN medication, as needed medication such as Madazlin, Paracetemol, Nurofin, Diazapan)
Name of
Medication		 Dose Frequency Route Purpose

Do I need assistance administering my medication?

If yes is there a Medication Authority/Administration log?

If yes has Medical Authority been explained to client and a copy given for GP to complete?

SUPPORT NEEDS
Self Care
Personal Care
Not required
Prompting
Standby assistance
Some support required
Moderate support required
Full support required
Details
Communication
Not required
Prompting
Standby assistance
Some support required
Moderate support required
Full support required
Details
Learning, applying
knowledge and general
tasks and demands
Not required
Prompting
Standby assistance
Some support required
Moderate support required
Full support required
Details
Community and
economic life
Not required
Prompting
Standby assistance
Some support required
Moderate support required
Full support required
Details
Working
Not required
Prompting
Standby assistance
Some support required
Moderate support required
Full support required
Details
Eating and Drinking
Not required
Prompting
Standby assistance
Some support required
Moderate support required
Full support required
Details
Mobility
Not required
Prompting
Standby assistance
Some support required
Moderate support required
Full support required
Details
Interpersonal
interactions and
relationships
Not required
Prompting
Standby assistance
Some support required
Moderate support required
Full support required
Details
Domestic Life
Not required
Prompting
Standby assistance
Some support required
Moderate support required
Full support required
Details
Toileting
Not required
Prompting
Standby assistance
Some support required
Moderate support required
Full support required
Details
Dietary requirements
Details
Home alone
assessment required
Home alone
assessment completed
COMMUNITY ACCESS
Activities attended
Likes
Dislikes
Animals
Use of wheelchair
Does the customer
handle their
own money?
Is the customer
transported in their own
vehicle?
Is the customer
transported in an LA's
vehicle?
MANUAL HANDLING
ALERTS FOR SUPPORT NOTES
ANY SPECIAL REQUIREMENTS FOR LA’S
Are there any care plans or behaviour plans?
Has a copy been provided to the office?
Can you provide us with a copy of your NDIS plan if you have received it (goals etc)
COMMUNICATION BOOK

EL/LAAS Representatives Name:

EL/LAAS Representatives Position:

Leave this empty:

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Signature Certificate
Document name: QF306 Individual Support Plan
lock iconUnique Document ID: cd2d366578b943779c94ce6c830c1a175b3e1eb2
Timestamp Audit
February 9, 2021 7:10 pm ACDTQF306 Individual Support Plan Uploaded by Meg Walker - admin@www.laas.com.au IP 125.168.64.82
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