Each Participant that receives Community Access & Capacity Building Supports is assigned to a Team Leader. Our Team Leaders are an important part of our support structure at Empowered Community Services. Each of our Team Leaders has first-hand experience in the field of Disability Support Work and uses their valuable experience to guide our Support Workers. Team Leaders are able to provide support to our Participants and are able to ensure that their supports remain person-centred and that each Participant is continually given the choice and control over their support plan. Team Leaders will be charged under Non-Face to Face Supports from the most relevant line item. This will be written in a Participants Service Agreement as Team Leader Assistance.
What is the participants primary disability? *
Does the participant have a secondary disability?
Please list secondary disability
Best way to communicate
Does the participant require culturally appropriate information?
Please describe the participants requirements
Reason for referral
Previous & current services
Details of any medications
Does the participant have any allergies?
Please clearly list each allergy and the reaction the participant may have
Does the participant have a pre existing health condition?
Please list information regarding health condition
Please list any dietary requirements
General Practitioner Details
Name of GP
GP Phone Number
Does the participant require medication to be administered during support hours?
Does the participant have a companion card?
Services Requested by the Participant
Has the participant consented to this referral?
Would the participant like any course of action to be taken in the event of no response to a scheduled visit? (For example, not answering the door)
What course of action should Empowered take in the event of a no response? (For example, call participants emergency contact)
Please note, Empowered has a minimum shift length of four hours for all new participants.*Participants who require less than a four support will be subject to approval and will depend on the total number of hours of support required per week*
Does the participant or other residents of the home have a history of aggressive violent or sexual behaviour?
Please provide details of history of aggressive, violet or sexual behaviour.
Do any neighbours have any relevant aggressive violent behaviours?
Please provide details of any neighbour's' aggressive violent behaviours.
Does the participant have any alcohol, gambling or substance abuse issues?
Please provide details of alcohol, gambling or substance abuse issues
Are there any pets at the property that may pose a risk of injuring a support worker, or escaping when a support worker enters the property?
Please provide details of any pets at the property that may pose a risk of injuring a support worker, or escaping when a support worker enters the property
Is the house inaccessible by a small, 2-wheel drive car?
Please provide details about access
Are any weapons located at the property? If so, are they safely locked away?
Please provide details of weapons
Are there issues with mobile reception at the property?
Please provide details of mobile reception issues
Do they have any history of self-harm, or suicidal ideation, or have they made suicidal attempts in the past?
Please provide details
Other Risks Referral Completed By
NDIS Goals *
Introduction to the Participant *
What outcomes would you like to see as a result of our service? *
Upload additional information such as participants NDIS plan
How did you hear about us?
Do you give consent for Empowered Community Services to use your image to share on their social media accounts, website & advertisements?
Do you consent to Empowered Community Services offering you other services that relate to your goals?
Do you agree to be given information about other services related to your goals and support needs whilst at Empowered Community Services?