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Support Requirement Information

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.
Parent/Carer Name:


Personal Details of Person Requiring Support



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.

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:

YLYC Host Services Required

Your Life Your Choice Package includes

Identified gaps in funding

Please tick to verify that you are not a robot

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