Sample

Mohit Sharma Personal Information Email Address mohitsharma810@gmail.com Date of birth September 4, 2023 NDIS reference number 4515151 Emergency contact name Adara Emergency contact phone number 108107419796 Disability(s) that impact Mohit's day to day life Autism Any other relevant medical history Asthma Allergies / drug reaction / other Ventolin How to respond in an emergency Call 911 Other relevant personal information –

Everyday Activities

Housework Needs some assistance with certain tasks (e.g. cleaning, garden maintenance) How to support &/or comments: 1

Shopping Completely unable and requires full support for shopping activities/tasks How to support &/or comments: 2

Transport Needs some assistance with transport (e.g. using public transport, assistance in getting in/out of a vehicle, carrying bags) How to support &/or comments: 3

Planning & Organising Needs some support in achieving day-to-day outcomes (e.g., appointments, maintaining schedule) How to support &/or comments: 4

Other everyday activities information –

Personal Care Mobility Requires no assistance with mobility; can move independently

How to support &/or comments: Paid support in place 1

Transfers (bed/chair) Needs some help (person and/or equipment) with transfers How to support &/or comments: Informal support in place 2

Bathing & showering – How to support &/or comments: Paid support in place, Informal support in place 3

Dressing – How to support &/or comments: Paid support in place, Informal support in place 4

Grooming – How to support &/or comments: Paid support in place 5

Oral care

– How to support &/or comments: Paid support in place 6

Meal preparation Needs some help with meal preparation and managing nutrition (e.g. portion control, meal planning) How to support &/or comments: Informal support in place 7

Eating & drinking – How to support &/or comments: Paid support in place, Informal support in place 8

Swallowing – How to support &/or comments: Paid support in place 9

Taking oral medication – How to support &/or comments: Informal support in place 10

Toileting – How to support &/or comments: Informal support in place 11

Continence – How to support &/or comments: Paid support in place, Informal support in place 12

Skin – How to support &/or comments: Paid support in place 13

Falls – How to support &/or comments: Informal support in place 14

Muscular pain – How to support &/or comments: Paid support in place 15

Nerve pain – How to support &/or comments: Informal support in place 16

Muscular issues other than pain No How to support &/or comments: Paid support in place 17

Sleep – How to support &/or comments: Paid support in place 18

Other personal care Fatigue, Visual disturbance, Temperature intolerance How to support &/or comments: Informal support in place 19

Communications Communication needs Requires no assistance; communicates effectively without any support

How to support &/or comments: Paid support in place 1

Vision Vision is impaired; wears glasses for improved vision; may need assistance with reading small print How to support &/or comments: Informal support in place 2

Hearing Does not use hearing aids; has normal hearing; no assistance required How to support &/or comments: Informal support in place 3

Telephone / Internet No help needed; able to independently use telephone and internet How to support &/or comments: Paid support in place 4

Other communication information – How to support &/or comments: Paid support in place, Informal support in place 5

Mental Health

Mood – Activities that help & other support strategies: Informal support in place What to avoid, e.g. staying in bed each day: Paid support in place, Informal support in place In this section, identify any mental health support (including any assistive technology and/or consumables) needs that Ryan may have by selecting an option from each drop down menu &/or select from the 'button' menu. Provide details in the 'Comments' box (if applicable) and tick if any paid or informal support is in place.

Coping skills Copes with most things well How to support &/or comments: Paid support in place In this section, identify any mental health support (including any assistive technology and/or consumables)

Coping strategies - needs prompting/assistance with: Deep breathing, Listening to music, Connecting with others Other support options: Paid support in place, Informal support in place Identify any mental health support (including any assistive technology and/or consumables) needs that Ryan may have by selecting an option from each drop down menu &/or select from the 'button' menu.

Concentration / Memory No concentration or memory problems; able to recall and focus without difficulty How to support &/or comments: Paid support in place

In this section, identify any mental health support (including any assistive technology and/or consumables) needs that Ryan may have by selecting an option from each drop down menu &/or select from the 'button' menu. Provide details in the 'Comments' box (if applicable) and tick if any paid or informal support is in place.

Other mental health information –

Financial & Legal Handling money Independent in banking, paying bills, and keeping track of finances; no assistance needed How to support &/or comments: Paid support in place, Informal support in place 1

Decision making – How to support &/or comments: Paid support in place 2

Will in place No When completed, by who (e.g. lawyer) where document located etc Informal support in place 3

Enduring Powers in place (e.g. Power of Attorney, Guardian, Advance Care Directive) No

When completed, by who (e.g. lawyer) where document located etc Paid support in place 4

Other relevant financial and legal information 5

Well Being Family & Friends Maintains relationships independently; no assistance needed How to support &/or comments: Paid support in place, Informal support in place 1

Exercise (sport, gym, massage, etc) Requires some help with planning, organising, or transportation for exercise activities How to support &/or comments: Paid support in place 2

Hobbies & interest Assistance always required to engage in hobbies and interests, including planning, organising, and transportation How to support &/or comments: Informal support in place 3

Social outings (cafe, movies, etc) Maintains activities independently; no assistance needed

How to support &/or comments: Paid support in place 4

Computer (games, online social activity, education) Maintains online relationships independently; no assistance needed How to support &/or comments: Informal support in place 5

Employment / Education / Volunteering Maintains activities and relationships independently; no assistance needed How to support &/or comments: Paid support in place 6

Religion or spiritual needs Requires some help with planning, organising, or transport for religious or spiritual activities How to support &/or comments: Informal support in place 7

Other well being information 8

Likes & Dislikes – Food, drinks, textures, flavours, etc.

Likes Pizza, Fried Chicken, Salad

Dislikes Broccoli, Burger

Likes & Dislikes – Music, movies, recreational activities etc.

Likes Abba Dislikes –

Likes & Dislikes – Other - sensory sensitivities, crowded places, etc.

Likes Chess Dislikes Baseball

Key Insights My routines – What makes me happy – What helps me to relax – What causes me stress – What makes me frustrated –

What makes me upset – Other insights –