Participants Name: Douglas GRAVES Date of Birth: 04/04/1969

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Address: 9 Sesame Street, Brisbane, Qld 4000 Phone: 07 3456 7890

TYPE OF RESPITE Social Activities

What do you want achieved from this respite? Primary Goal

Promote social engagements with community members

Sub Goal 1:

Engage in cognitively stimulating activities

Sub Goal 2:

Reduce hoarding behaviour through diversional activities

Sub Goal 3:

Maintain personal independence ensuring opportunities given of choice

Preferred Start Date: 21/01/20XX

Frequency of Respite: Daily / Weekly / Fortnightly / Monthly / Occasionally

(Highlight which is applicable)

Preferred DAY and TIME (Fill in times next to the relevant day of the week)

Monday 9:00am to 2:00pm Friday Tuesday 9:00am to 2:00pm Saturday Wednesday Sunday Thursday 9:00am to 2:00pm PICK UP AND DROP OFF DETAILS

Contact Person: Enid Kelly (Live in carer) Ph: 07 3456 7890

Pick Up Address: 9 Sesame Street, Brisbane, Qld 4000 Restrictions on pick up: N/A

Contact Person: As above Ph: As above

Drop off Address: As above Restrictions on drop off: N/A

EMERGENCY CONTACT DETAILS

Name of Person and Contact No: Enid Kelly (Live in carer) Ph. 07 3456 7890

Name of 2nd Person and Contact No: Ted Black (Friend) Ph. 0413 333 444

Does the Participant have a Behavioural Support Plan? Yes / No (Highlight)

If Yes, please supply a copy of the Behavioural Support Plan as part of the Respite Care Plan

MEDICAL CONDITION/DISABILITY/DISABILITIES - TYPE/SPECIAL NEEDS

Allergies: Shellfish

Early Onset Dementia

Heart Disease

Arthritis

HEALTH ISSUES THAT REQUIRE SPECIALISED TREATMENT WHILE IN RESPITE

ASTHMA: Yes / No If Yes, please attach Asthma Plan

Any other Medical Conditions that require specialised treatment:

Please attach any treatment plans.

FOODS ALLERGIES OR SENSITIVITIES - WHAT FOODS MUST BE AVOIDED

Nil Known

Any Special Requirements or Cultural Considerations in regard to Food Other Dietary Requirements (Likes/Dislikes):

Full diet

Enjoys his food. Needs non-slip place mat under plate with guard. Likes to eat socially. Low fat and salt diet.

Has difficulty holding handles due to arthritis. Provide with modified mug. Likes:

Food: Most foods especially any meat with vegetables.

Drink: Coffee, beer, soft drink (lemon, lemonade, coke).

Dislikes: Allergy to shellfish

Food: Seafood.

Drink: Wine.

AIDS AND EQUIPMENT REQUIREMENTS

e.g. Walking Frame, Wheelchair, Bath Chair, Toilet Chair, special cutlery etc.

Doug requires a wheelchair for mobility. Transfer with full sling hoist.

PERSONAL CARE NEEDS

For each of the following tasks, please circle relevant response and add comment if required.

Dress/Undress Independently / Requires Assistance / Full Assistance

Selection of clothing Independently / Requires Assistance / Full Assistance

Bathe/Showering Independently / Requires Assistance / Full Assistance

Grooming Independently / Requires Assistance / Full Assistance

Dental hygiene Independently / Requires Assistance / Full Assistance

Eat a meal Independently / Requires Assistance / Full Assistance

Transfer in and out of bed/chair Independently / Requires Assistance / Full Assistance

Walk 50 metres indoors Independently / Requires Assistance / Full Assistance

Uses wheelchair for mobility.

Walk 50 metres outdoors/uneven surfaces Independently / Requires Assistance / Full Assistance

Uses wheelchair for mobility.

Continent of Urine Independently / Requires Assistance / Full Assistance

Doug uses incontinence pad throughout the day. A full sling hoist will be required to change pad.

Continent of Faeces Independently / Requires Assistance / Full Assistance

Doug will inform staff the need to use the toilet. A full sling hoist will be required to place Doug onto a shower chair/commode.

Comments: Doug requires a wheelchair for mobility. Transfer with full sling hoist.

OTHER NEEDS

Describe the following at present: Occurrences and Triggers Action For Best Outcome

Communication skills:

Doug comes from English speaking background. Can communicate easily. Ensure you speak clearly and away from background noise.

Vision:

Wears glasses for reading and close work. All interactions. Clean glasses as required. Ensure adequate lighting for Dougs reduced vision.

Hearing:

Has slight hearing loss in both ears. All interactions. Ensure you speak clearly and away from background noise.

Behavioural:

Doug has a very short attention span and is a chronic hoarder. All interactions and activities. Requires continual prompting for participation and diversional strategies to reduce hoarding.

Socially:

Doug worked as a labourer on the railway in outback Queensland. He never married and has a brother in north Qld. An old friend Ted Black visits about once per month. They have a few beers and reminisce. Encourage friendships and social interaction. Encourage Doug to attend social activities.

Ensure private area for Doug and Ted to chat and drink.

Cultural/Spiritual/Sexual Considerations:

Nil stated. Activities enjoyed:

Country and Rock n Roll Music, Poker, TV westerns, darts, lawn bowls, Australian poetry. Ensure Doug is given every opportunity to be involved in his preferred activities.

Any major triggers in general:

Becomes frustrated at times with his limitations. Ensure ample time is given and is never rushed. Praise his efforts.

RECORD ANY OTHER INFORMATION THAT WILL ASSIST IN MATCHING PARTICIPANT WITH RESPITE CARE WORKER NOT COVERED ABOVE:

Signed: Date: Office Use Only - Service Coordinators Notes

Participants Name NDIA No: Notes:

Service Coordinator: Date:

Participants Name: Dan SING Date of Birth: 12/04/1949

Address: 43 Board Circuit, Brisbane, Qld 4000 Phone: 07 234 56789

TYPE OF RESPITE Social Activities

What do you want achieved from this respite? Primary Goal

Promote social engagements with community members

Sub Goal 1:

Engage in cognitively stimulating activities

Sub Goal 2:

Reduce hoarding behaviour through diversional activities

Sub Goal 3:

Maintain personal independence ensuring opportunities given of choice

Preferred Start Date: 21/01/20XX

Frequency of Respite: Daily / Weekly / Fortnightly / Monthly / Occasionally

(Highlight which is applicable)

Preferred DAY and TIME (Fill in times next to the relevant day of the week)

Monday Friday 9:00am to 2:00pm

Tuesday 9:00am to 2:00pm Saturday Wednesday Sunday Thursday 9:00am to 2:00pm PICK UP AND DROP OFF DETAILS

Contact Person: Rae Sing (Sister/Carer) Ph: 07 234 56789

Pick Up Address: 43 Board Circuit, Brisbane, Qld 4000 Restrictions on pick up: N/A

Contact Person: As above Ph: As above

Drop off Address: As above Restrictions on drop off: N/A

EMERGENCY CONTACT DETAILS

Name of Person and Contact No: Rae Sing (Sister/Carer) Ph. 07 234 56789

Name of 2nd Person and Contact No: John Sing (Nephew) Ph. 0413 345 678

Does the Participant have a Behavioural Support Plan? Yes / No (Highlight)

If Yes, please supply a copy of the Behavioural Support Plan as part of the Respite Care Plan

MEDICAL CONDITION/DISABILITY/DISABILITIES - TYPE/SPECIAL NEEDS

Falls Risk

CVA (L)

GORD

Dysphagia

Dysphasia

Hearing Impairment

HEALTH ISSUES THAT REQUIRE SPECIALISED TREATMENT WHILE IN RESPITE

ASTHMA: Yes / No If Yes, please attach Asthma Plan

Any other Medical Conditions that require specialised treatment:

Please attach any treatment plans.

FOODS ALLERGIES OR SENSITIVITIES - WHAT FOODS MUST BE AVOIDED

Nil Known

Any Special Requirements or Cultural Considerations in regard to Food Other Dietary Requirements (Likes/Dislikes):

Full diet

Pureed food due to dysphagia. Uses large handled cutlery. Dan likes to be in the dining room for all meals.

Thickened fluids required thickened. Requires cup with handle. Likes:

Food: Roasts, vegetables, desserts.

Drink: Coffee, juice, soft drink, occasional light beer.

Dislikes:

Food: Seafood, salad.

Drink: Tea, cordial.

AIDS AND EQUIPMENT REQUIREMENTS

e.g. Walking Frame, Wheelchair, Bath Chair, Toilet Chair, special cutlery etc.

Limited movement on R side. Is able to mobilise with assistance. Has brace for R lower leg. Needs prompting to not swing R leg outwards when mobilising. Walks with the aid of a 4-pronged walking stick and walk belt. Is unsteady from sitting to standing.