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?: | * |
| Choose one statement which best describes the service you are seeking: | * |
| What best describes your relationship to the person requiring support? : | * |
| Parent/Carer First Name: | * |
| Parent/Carer Last Name: | * |
| Address: | * |
| City/Suburb: | * |
| Postcode: | * |
| Parent/Carer Email address: | * |
| Mobile Number: | * |
| Do you have a smart phone?: | |
| Skype Address: | |
| Preferred Contact Method: | |
Personal Details of Person Requiring Support |
| Participant's age: | * |
| First Name: | * |
| Last Name: | * |
| Address: | |
| City/Suburb: | |
| Postcode: | |
| Date of birth: |  * |
| Telephone: | |
| Mobile Number: | |
| Do you have a smart phone?: | |
| Email Address: | * |
| Skype Address: | |
| Website URL: | |
| Facebook Address: | |
| Preferred Contact Method: | * |
| Marital Status: | * |
| Do you have children under 18 years?: | |
| How many children do you have?: | |
| Please specify your ethnicity: | |
| Employment Status: Are you currently...: | |
| Education: Highest level completed: | |
| Do you have an electronic personal health record: | |
| Do you have a diagnosis?: | * |
| What is your diagnosis?: | * |
| Please list any other medical conditions you may have: | * |
| I am registered with Disability Services: | * |
| I attend therapy: | |
| No. of hours per week of therapy: | |
| Therapy I attend is: | |
| I attend lifestyle activities: | |
| No. of hours per week of lifestyle activities: | |
| Lifestyle activities I attend are: | |
| I need a support worker: | |
| I need personal care: | |
| I need problem solving support: | |
| I need cognitive support.: | |
| I need life skill support like cooking.: | |
| I need community access support: | |
| Describe your preferred personality in a support worker.: | |
| What is your preferred support worker gender: | |
| What strength should your support worker be: | |
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. : * | 1 Strongly Agree
2 Moderately Agree
3 Agree
4 Disagree
5 Moderately Disagree
6 Strongly Disagree
|
| 2. As to my health, what will be will be. : * | 1 Strongly Agree
2 Moderately Agree
3 Agree
4 Disagree
5 Moderately Disagree
6 Strongly Disagree
|
| 3. If I see my doctor regularly, I am less likely to have problems with my health. : * | 1 Strongly Agree
2 Moderately Agree
3 Agree
4 Disagree
5 Moderately Disagree
6 Strongly Disagree
|
| 4. Most things that affect my health happen to me by chance. : * | 1 Strongly Agree
2 Moderately Agree
3 Agree
4 Disagree
5 Moderately Disagree
6 Strongly Disagree
|
| 5. Whenever my health worsens, I should consult a medically trained professional. : * | 1 Strongly Agree
2 Moderately Agree
3 Agree
4 Disagree
5 Moderately Disagree
6 Strongly Disagree
|
| 6. I am directly responsible for my health getting better or worse. : * | 1 Strongly Agree
2 Moderately Agree
3 Agree
4 Disagree
5 Moderately Disagree
6 Strongly Disagree
|
| 7. Other people play a big role in whether my health improves, stays the same, or gets worse. : * | 1 Strongly Agree
2 Moderately Agree
3 Agree
4 Disagree
5 Moderately Disagree
6 Strongly Disagree
|
| 9. Luck plays a big part in determining how my health improves. : * | 1 Strongly Agree
2 Moderately Agree
3 Agree
4 Disagree
5 Moderately Disagree
6 Strongly Disagree
|
| 10. In order for my health to improve, it is up to other people to see that the right things happen. : * | 1 Strongly Agree
2 Moderately Agree
3 Agree
4 Disagree
5 Moderately Disagree
6 Strongly Disagree
|
| 11. Whatever improvement occurs with my health is largely a matter of good fortune. : * | 1 Strongly Agree
2 Moderately Agree
3 Agree
4 Disagree
5 Moderately Disagree
6 Strongly Disagree
|
| 12. The main thing which affects my health is what I myself do. : * | 1 Strongly Agree
2 Moderately Agree
3 Agree
4 Disagree
5 Moderately Disagree
6 Strongly Disagree
|
| 13. I deserve the credit when my health improves and the blame when it gets worse.: * | 1 Strongly Agree
2 Moderately Agree
3 Agree
4 Disagree
5 Moderately Disagree
6 Strongly Disagree
|
| 14. Following doctor's orders to the letter is the best way to keep my health from getting any worse. : * | 1 Strongly Agree
2 Moderately Agree
3 Agree
4 Disagree
5 Moderately Disagree
6 Strongly Disagree
|
| 15. If my health worsens, it's a matter of fate. : * | 1 Strongly Agree
2 Moderately Agree
3 Agree
4 Disagree
5 Moderately Disagree
6 Strongly Disagree
|
| 16. If I am lucky, my health will get better.: * | 1 Strongly Agree
2 Moderately Agree
3 Agree
4 Disagree
5 Moderately Disagree
6 Strongly Disagree
|
| 17. If my health takes a turn for the worse, it is because I have not been taking proper care of myself. : * | 1 Strongly Agree
2 Moderately Agree
3 Agree
4 Disagree
5 Moderately Disagree
6 Strongly Disagree
|
| 18. The type of help I receive from other people determines how soon my health improves.: * | 1 Strongly Agree
2 Moderately Agree
3 Agree
4 Disagree
5 Moderately Disagree
6 Strongly Disagree
|
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: | * |
| 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: | |
| Please give an indication of the level of service you prefer: | |
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? : | |
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