Get to Know You C2C - Care Squared

Get to Know You C2C Program

Welcome to Care Squared Connect!

In preparation for our next program, we’d like to get to know you a little better.

Please complete the following form so we can cater for your individual needs at the up coming event.

"*" indicates required fields

Participant name:

First Last

Your availability to attend Care Squared Connect programs:*

Monday

Tuesday

Wednesday

Thursday

Friday

Preferred time:*

Either

Are there any days/times that are unsuitable?*

What is listed as the primary disability in your NDIS plan?*

Hidden

How would you rate your/the participants level of independence?

How would you rate your/the participants level of independence?*

1 (high functioning - independent)

2 (moderate functioning - needs support sometimes)

3 (low functioning - needs full time support)

Please provide more information:

Have you/the participant attended group programs in the past?

Yes

Are there any behaviours of concern that clinicians need to be aware of within the group setting?*

Are there any other medical conditions we should be aware of?

Yes

If yes, please add:

Are there any behaviours of concern that we need to consider?

Yes

If yes, please add:

Support person

Will they be bringing a support person/carer/support worker to the group with them?

Yes

Support person's name*

First Last

Support person's phone number*

Are there are communication or learning considerations we need to be aware of to support the participant?

Yes

If yes, please add:*

Mobility status:

Wheel chair

Frame

Crutches

Access to lifts

Walk endurance

Independence

Other

Please add details, if required:

How do you foresee that they will benefit from attending these sessions?

Please list the participants NDIS goals and identify the purpose for the referral into this program:*

Emergency contact

Name:*

First Last

Phone number:*

Acceptance of Schedule of Supports:*

I agree that I have read the Terms and Conditions supplied in the Schedule of Support sent to me by email and that the completion of this form is an acceptance of my quote. By adding my name below, I agree to the above.

First name (of pesron completing this form) Last name (of person completing this form)

About Care Squared

Our Services

Care Squared Connect

Get to Know You C2C Program

Welcome to Care Squared Connect!

Support person

Emergency contact

Request a call back

Get to Know You C2C Program

Welcome to Care Squared Connect!

Support person

Emergency contact

Your Privacy

Stay up to date with our events and group programs!

Request a call back