Support Requirements Questionnaire Please answer the following questions and we will develop a personalised plan to support you to achieve your goals. Your information will be deleted from our records if you do not use our services. Should you require support worker broker services, your information will be provided to our preferred supplier. Which statement best describes you?: I am a person with disability requiring support I am a carer of a person with disability requiring support Choose one statement which best describes the service you are seeking: A host provider for my YLYC funding Funding for unmet disability needs Baby Bridges Program Participant What best describes your relationship to the person requiring support? : Parent Partner Sibling Carer Other Parent/Carer First Name: Parent/Carer Last Name: Address: City/Suburb: Postcode: Parent/Carer Email address: Mobile Number: Do you have a smart phone?: Yes No Skype Address: Preferred Contact Method: Telephone Email Skype Mail Face to Face Personal Details of Person Requiring Support Participant's age: Over 18 years old Under 18 years old First Name: Last Name: Address: City/Suburb: Postcode: Date of birth: dd 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 mm 01 02 03 04 05 06 07 08 09 10 11 12 yyyy 1924 1925 1926 1927 1928 1929 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 2022 2023 2024 2025 2026 2027 2028 Telephone: Mobile Number: Do you have a smart phone?: Yes No Email Address: Skype Address: Website URL: Facebook Address: Preferred Contact Method: Email Telephone Skype Mail Marital Status: Single, never married Married or domestic partnership Widowed Divorced Separated Prefer not to answer Do you have children under 18 years?: Yes No How many children do you have?: Please specify your ethnicity: Employment Status: Are you currently...: Employed for wages Self-employed Out of work and looking for work Out of work but not currently looking for work A homemaker A student Military Education: Highest level completed: No schooling completed Preschool to 8th grade Some high school, no diploma High school graduate, diploma or the equivalent Some university credit, no degree Trade/technical/vocational training Associate degree Bachelor’s degree Master’s degree Professional degree Doctorate degree Prefer not to answer Do you have an electronic personal health record: Yes No I don't know Do you have a diagnosis?: Yes No What is your diagnosis?: Please list any other medical conditions you may have: I am registered with Disability Services: Yes No I attend therapy: Yes No No. of hours per week of therapy: Therapy I attend is: I attend lifestyle activities: Yes No No. of hours per week of lifestyle activities: Lifestyle activities I attend are: I need a support worker: Yes No I need personal care: Yes No I need problem solving support: Yes No I need cognitive support.: Yes No I need life skill support like cooking.: Yes No I need community access support: Yes No Describe your preferred personality in a support worker.: What is your preferred support worker gender: Female Male What strength should your support worker be: Strong Medium Fair The questions below will help us understand how you are feeling about your current situation. Instructions: Each item below is a belief statement about your medical health with which you may agree or disagree. Beside each statement is a scale which ranges from strongly disagree (1) to strongly agree (6). For each item we would like you to choose the number that represents the extent to which you agree or disagree with that statement. The more you agree with a statement, the higher will be the number you choose. The more you disagree with a statement, the lower will be the number you choose. Please make sure that you answer EVERY ITEM. This is a measure of your personal beliefs; obviously, there are no right or wrong answers. 1. If my health worsens, it is my own behaviour which determines how soon I will feel better again. : * 2. As to my health, what will be will be. : * 3. If I see my doctor regularly, I am less likely to have problems with my health. : * 4. Most things that affect my health happen to me by chance. : * 5. Whenever my health worsens, I should consult a medically trained professional. : * 6. I am directly responsible for my health getting better or worse. : * 7. Other people play a big role in whether my health improves, stays the same, or gets worse. : * 9. Luck plays a big part in determining how my health improves. : * 10. In order for my health to improve, it is up to other people to see that the right things happen. : * 11. Whatever improvement occurs with my health is largely a matter of good fortune. : * 12. The main thing which affects my health is what I myself do. : * 13. I deserve the credit when my health improves and the blame when it gets worse.: * 14. Following doctor's orders to the letter is the best way to keep my health from getting any worse. : * 15. If my health worsens, it's a matter of fate. : * 16. If I am lucky, my health will get better.: * 17. If my health takes a turn for the worse, it is because I have not been taking proper care of myself. : * 18. The type of help I receive from other people determines how soon my health improves.: * My Vision/Goals Developing and sharing a vision for your life (whether short or long term) focuses your efforts and resources and provides good information for the people supporting you. Below are some prompts which may wish to complete and some examples: I would like to share my vision/goals: Yes No Family: Personal Relations: Sexuality: Learning: Paid Employment: Community work/volunteering: Accommodation: Health: Recreation: Other: YLYC Host Services Required I would like a free Personalised Proposal: Yes No Please give an indication of the level of service you prefer: I would like to take full responsibility I would like to take most responsibility I would like to take less responsibility Your Life Your Choice Package includes Respite Package: Accommodation: In Home Support: Community Access: Other: Identified gaps in funding What is the amount of funding required?: What are your unmet needs? :
