My Support Plan Basic informationFunctional requirementsHealth requirementsSocial RequirementsBehavioural requirementsMy Support plan – TemplateA list of the things that determine the care I needName DOB Address Address Line 1CitySouth AustraliaAustralian Capital TerritoryNew South WalesNorthern TerritoryQueenslandSouth AustraliaTasmaniaVictoriaWestern AustraliaState / Province / RegionZip / Postal CodeHome phone Mobile Work Email Living arrangements (who do you live with?)Living environment (e.g. unmodified or modified home/unit for my needs, supported accommodation)Carer Name (if applicable)Address Address Line 1CitySouth AustraliaAustralian Capital TerritoryNew South WalesNorthern TerritoryQueenslandSouth AustraliaTasmaniaVictoriaWestern AustraliaState / Province / RegionZip / Postal CodeHome phone Mobile Work Email Diagnosis Date of Diagnosis Medical History GP Name Address Address Line 1CitySouth AustraliaAustralian Capital TerritoryNew South WalesNorthern TerritoryQueenslandSouth AustraliaTasmaniaVictoriaWestern AustraliaState / Province / RegionZip / Postal CodeWork Email What is important to you? What are your goals for the next 12 months? My regular routine and activities in a typical weekUse this table to help you identify all the things you do each dayMonday Time 6.00-7.00 am7.00-8.00 am8.00-9.00 am9.00-10.00 am10.00-11.00 am11.00-12.00 pm12.00 – 1.00 pm1.00-2.00 pm2.00-3.00 pm3.00-4.00 pm4.00-5.00 pm5.00-6.00 pm6.00-7.00 pm7.00-8.00 pm8.00-9.00 pm9.00-10.00 pm10.00 pm +Activities Please click "add" to add another time and activitiesAdd RemoveTuesday Time 6.00-7.00 am7.00-8.00 am8.00-9.00 am9.00-10.00 am10.00-11.00 am11.00-12.00 pm12.00 – 1.00 pm1.00-2.00 pm2.00-3.00 pm3.00-4.00 pm4.00-5.00 pm5.00-6.00 pm6.00-7.00 pm7.00-8.00 pm8.00-9.00 pm9.00-10.00 pm10.00 pm +Activities Please click "add" to add another time and activitiesAdd RemoveWednesday Time 6.00-7.00 am7.00-8.00 am8.00-9.00 am9.00-10.00 am10.00-11.00 am11.00-12.00 pm12.00 – 1.00 pm1.00-2.00 pm2.00-3.00 pm3.00-4.00 pm4.00-5.00 pm5.00-6.00 pm6.00-7.00 pm7.00-8.00 pm8.00-9.00 pm9.00-10.00 pm10.00 pm +Activities Please click "add" to add another time and activitiesAdd RemoveThursday Time 6.00-7.00 am7.00-8.00 am8.00-9.00 am9.00-10.00 am10.00-11.00 am11.00-12.00 pm12.00 – 1.00 pm1.00-2.00 pm2.00-3.00 pm3.00-4.00 pm4.00-5.00 pm5.00-6.00 pm6.00-7.00 pm7.00-8.00 pm8.00-9.00 pm9.00-10.00 pm10.00 pm +Activities Please click "add" to add another time and activitiesAdd RemoveFriday Time 6.00-7.00 am7.00-8.00 am8.00-9.00 am9.00-10.00 am10.00-11.00 am11.00-12.00 pm12.00 – 1.00 pm1.00-2.00 pm2.00-3.00 pm3.00-4.00 pm4.00-5.00 pm5.00-6.00 pm6.00-7.00 pm7.00-8.00 pm8.00-9.00 pm9.00-10.00 pm10.00 pm +Activities Please click "add" to add another time and activitiesAdd RemoveSaturday Time 6.00-7.00 am7.00-8.00 am8.00-9.00 am9.00-10.00 am10.00-11.00 am11.00-12.00 pm12.00 – 1.00 pm1.00-2.00 pm2.00-3.00 pm3.00-4.00 pm4.00-5.00 pm5.00-6.00 pm6.00-7.00 pm7.00-8.00 pm8.00-9.00 pm9.00-10.00 pm10.00 pm +Activities Please click "add" to add another time and activitiesAdd RemoveSunday Time 6.00-7.00 am7.00-8.00 am8.00-9.00 am9.00-10.00 am10.00-11.00 am11.00-12.00 pm12.00 – 1.00 pm1.00-2.00 pm2.00-3.00 pm3.00-4.00 pm4.00-5.00 pm5.00-6.00 pm6.00-7.00 pm7.00-8.00 pm8.00-9.00 pm9.00-10.00 pm10.00 pm +Activities Please click "add" to add another time and activitiesAdd RemoveComment Functional requirementsHousework Can maintain home without help (including laundry)Need some assistance (cleaner, change light bulb)Completely unable to do houseworkProvide details of the aids and assistance required, from whom and when Transport No help needed (drives own car, or travels independently on public transport or by taxi)Need some help (someone to drive or accompany when travelling)Can only travel in specialised vehicleProvide details of the aids and assistance required, from whom and when Shopping (has transport) Can take care of all shopping needs on own (including internet shopping)Need some help (someone to accompany on most shopping trips)Completely unable to do any shoppingProvide details of the aids and assistance required, from whom and when Meal preparation No help needed (can plan, prepare, cook and ensure nutrition)Need some helpCompletely unable to prepare meals and manage nutritionProvide details of the aids and assistance required, from whom and when Eating No help neededSome help needed (cutting up food, spreading butter, pouring drink, modified cutlery)Completely unable to eat without help (spoon feeding)Provide details of the aids and assistance required, from whom and when Taking oral medication No help needed (right dose and right time)Need some help (someone prepares, reminds, pre-packed)Completely unable to take own medicines without helpProvide details of the aids and assistance required, from whom and when Handling money No help needed (banking, paying bills, keeping track of finances)Need some help (can manage day to day buying but needs help with paying bills)Completely unable to manage moneyProvide details of the aids and assistance required, from whom and when Telephone No help needed (can make and receive phone calls including using assistive devices)Needs some helpCompletely unable to use telephoneProvide details of the aids and assistance required, from whom and when Mobility No help needed (except use of stick)Need some help (person, walker, crutches or self-propelled wheelchair including cornering)Completely unable to walk or needs to be pushed in wheelchairProvide details of the aids and assistance required, from whom and when Transfers Bed/chair No help neededNeed some help (person or equipment)Unable to manage (unable to balance while sitting)Provide details of the aids and assistance required, from whom and when Bathing Showering No help needed (get in and out of bath/shower and wash unaided)Need some help (rails, shower chair, person to shampoo hair) but can wash themselvesCompletely unable to bathe/shower on ownProvide details of the aids and assistance required, from whom and when Oral care No help needed (includes using electric toothbrush)Need some help (prompting)Completely unable to manage mouth care and cleaning teethProvide details of the aids and assistance required, from whom and when Dressing No help neededNeed some help (zips, buttons, laces but can put on some garments)Completely unable to dressProvide details of the aids and assistance required, from whom and when Grooming (makeup, hair, nails, shaving) No help neededNeed some helpCompletely unable to manage any grooming without helpProvide details of the aids and assistance required, from whom and when Toileting No help needed (can get on and off, remove clothing and clean thoroughly)Need some helpCompletely unable to manage toileting without helpProvide details of the aids and assistance required, from whom and when Health requiementsContinence Continent with regular bowel and bladder actionConstipation, diarrhoea or incontinence (using medication, supplements, pads)Medical interventions (catheter, stoma bag)Outline condition, treatments, aids/assistance required, from whom and when Skin Integrity No skin problemsSome skin problems (rash, skin treatments)Pressure areas (currently have, at risk, or had in past)Outline condition, treatments, aids/assistance required, from whom and when Swallowing No swallowing issuesSome swallowing problems (choking, coughing during normal meal, reduced appetite)Major swallowing difficulties (modified diet, feeding tube)Outline condition, treatments, aids/assistance required, from whom and when (copy) Health professionals Have had a GP check up in the last 12 monthsSee a specialist regularlyHave a case manager/support coordinatorOutline condition, treatments, aids/assistance required, from whom and when Muscular pain No painModerate painSevere painOutline condition, treatments, aids/assistance required, from whom and when Falls No falls in past 12 monthsLess than 3 falls and no serious injury from a fall in past 12 monthsMore than 3 falls or a serious injury from a fall in the past yearOutline condition, treatments, aids/assistance required, from whom and when Muscular issues (other than pain) No problemsSome muscle weakness, tremor, spasms, spasticity or problems with balanceSerious muscle weakness, tremor, spasticity or problems with balanceOutline condition, treatments, aids/assistance required, from whom and when Other health concerns FatigueVisual disturbanceTemperature intoleranceOther comorbiditiesOutline condition, treatments, aids/assistance required, from whom and when Social RequirementsActivities Example: Outline how you want to do this activity Provide details of the activity, the time spent, the assistance required, from whom and when (including vouchers) 1. Family Outline how you want to do this activity Provide details of the activity, the time spent, the assistance required, from whom and when (including vouchers) 2. Hobbies and Interests Outline how you want to do this activity Provide details of the activity, the time spent, the assistance required, from whom and when (including vouchers) 3. Outings: e.g. theatre, cafes, exhibitions, drives, groups activities Outline how you want to do this activity Provide details of the activity, the time spent, the assistance required, from whom and when (including vouchers) 4. Computer: e.g. games, shopping, education, booking Outline how you want to do this activity Provide details of the activity, the time spent, the assistance required, from whom and when (including vouchers) 5. Employment: Education, Volunteering Outline how you want to do this activity Provide details of the activity, the time spent, the assistance required, from whom and when (including vouchers) 6. Sports Outline how you want to do this activity Provide details of the activity, the time spent, the assistance required, from whom and when (including vouchers) 7. Music: Likes, dislikes Outline how you want to do this activity Provide details of the activity, the time spent, the assistance required, from whom and when (including vouchers) 8. Movies/TV: Likes, dislikes Outline how you want to do this activity Provide details of the activity, the time spent, the assistance required, from whom and when (including vouchers) 9. Well-being: e.g. exercise, gym, swimming pool, massage, yoga, meditation etc. Outline how you want to do this activity Provide details of the activity, the time spent, the assistance required, from whom and when (including vouchers) 10. Food and alcohol: Likes, dislikes, diets Outline how you want to do this activity Provide details of the activity, the time spent, the assistance required, from whom and when (including vouchers) Other comment Behavioural requirementsCommunication No assistance required (including independent use of aids and adaptive technology)Some assistance required (prompting, assistance with aids)Assistance always requiredOutline the issue, aids, assistance and management strategies required Memory problems Confusion NoYesOutline the issue, aids, assistance and management strategies required Concentration problems NoYesOutline the issue, aids, assistance and management strategies required Planning problems NoYesOutline the issue, aids, assistance and management strategies required Spiritual needs NoYes (name religion or spiritual affiliation and requirements)Outline the issue, aids, assistance and management strategies required Mood Mostly positiveExperiences sadness, anxiety or emptiness around 50% of timeFeelings of anxiety, sadness or emptiness lasting most of the day, nearly every dayOutline the issue, aids, assistance and management strategies required Decision making No help neededNeed some helpNot able to make any decisionsOutline the issue, aids, assistance and management strategies required WebsitePreviousNextSubmit Save and Continue