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 Email address:

Mobile Number:

Do you have a smart phone?:

Skype Address:

Preferred Contact Method:

Personal Details of Person Requiring Support

Participant's age:

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.: