Interaction

Participant Name

Name:

Date of Birth:

Email:

Phone

Are you completing on behalf of a participant?YesNo

If completing on behalf of participant:

Name:

Relationship to participant:

Email:

Phone

Are you authorised to provide information on behalf of participant?: YesNo

Diagnosis

Medical conditions

Type of accommodation service required?

For a detailed description of each category please click on the category name. If the location required is not listed in this section, please refer to ‘Preferred location’ section further on.

Shared & Supported – Sydney
24 hour active24 hour sleepover
Transitional Living – Central Coast
24 hour active24 hour sleepover
Empowered Living Apartments™
24 hour less intensive - Mt Gravatt, QLD24 hour less intensive - Cranebrook, NSW

Preferred location for accommodation and level of support required (eg 24 hour active night, 24 hour sleepover).

Who will help or be involved in transition?

Parents/GuardianLocal Area CoordinatorSpecialist Support CoordinatorSupport CoordinatorCurrent service provider

Who would you like to live with?

Males onlyFemales onlyMixed gender

Is there a requirement for equipment or aides?

YesNo

If Yes, Please Specify:

Is there support required with personal care routine?

YesNo

If Yes, Please describe support required:

Is there support required to access the community?

YesNo

If Yes, please specify:

Is there support required with domestic skills?

YesNo

If Yes, please describe support required:

Communication

VerbalNon VerbalAuslan

How are participants personal funds managed?

Independently manageRequire staff support to manageCarer or parent managesUnder Financial Management

Employment

EmployedDay ServiceOther

If Other, please specify:

Location:

Days and times:

Is there a Behaviour Support Plan?

YesNo

If there is no Behaviour Support Plan in place, please describe below any behaviours we need to be aware of (e.g. property damage, physical assault others, self harm, non compliance, verbal aggression)

Are there any typical triggers for these behaviours (e.g. change to my routine, heat, being sick)

Previously lived in supported accommodation?

YesNo

If yes, why are you, or why did you choose to leave?

Accommodation Services

PWS Accommodation Expression Of Interest Form

Participant Name

If completing on behalf of participant:

Diagnosis

Medical conditions

Type of accommodation service required?

Preferred location for accommodation and level of support required (eg 24 hour active night, 24 hour sleepover).

Who will help or be involved in transition?

Who would you like to live with?

Is there a requirement for equipment or aides?

Is there support required with personal care routine?

Is there support required to access the community?

Is there support required with domestic skills?

Communication

How are participants personal funds managed?

Employment

Is there a Behaviour Support Plan?

Previously lived in supported accommodation?

What is important to you, (or the person on whose behalf you are completing this for) in relation to preferred accommodation services?

Any other comments?