Expression of Interest Form

EXPRESSION OF INTEREST

Enquirer First Name

Enquirer Last Name *

Enquirer Relationship to Participant

Enquirer Mobile Number

Enquirer Email Address

Participant First Name

Participant Last Name

Participant Preferred Pronouns

Please specify your pronouns

Age

Date of Birth

Do you have sufficient funding in your current plan for these selected services?Please enter Yes if you have sufficient funding and indicate funding type. Please enter No if you currently do no have sufficient funding.

How did you hear about Onemda :

Interested Services

Group Services Therapy ServicesXTEND (after hours service 3-7pm)

Select all that apply

Primary Disability

Secondary disability

Other Disability Please Specify

Do you identify as Aboriginal or Torres Strait Islander?

Interpreter Required?

Any Specific Considerations or Preferences

Language required

Other Language

INITIAL FOLLOW UP (TO BE COMPLETED BY ONEMDA INTAKE TEAM)

Intake Team Member *

Email Address

Primary disability – Intellectual disability is primary

Age – Group services over 18, Therapy over 16

Vaccination within last 12 months

Requested services – Requesting group service, XTEND and/or therapy.

Funding – E.g. NDIS plan with funding, Fee For Service, Private, MBS, TAC, Worksafe

Campus Tour *

Reason for not proceeding

INTERVIEW (To be completed by Onemda Intake Team)

Participant's Details

Participant Name

Preferred Name

Preferred Pronouns

Covid Vaccination - date of last vaccination (if vaccinated)Strongly encouraged but not compulsory

Intake Interview Details

Intake Interview Date

How Was The Intake Interview Held

Intake Interview Conducted with

Relationship To The Participant

Intake Interview Conducted with 2

Relationship To The Participant 2

Is this person the Plan Nominee

Participant Present

Does the plan nominee know about the enquiry/application for services

Who spoke on their behalf and why the participant is not present

NDIS Plan Nominee Details

First Name

Last Name

Preferred Name

Address

Email Address

Contact Number

Relationship With Participant

Consent to Act

Do you consent to sharing your NDIS Plan with us?

Family or Carer considerationsi.e., are there any other people we need to communicate with, are any court orders in place. Any specific family dynamics we need to be aware of.

Living Arrangements

Specify Living Arrangements

What current supports do you have in place

Session Fees and POS have been explained

Emergency Contact

Full Name

Relationship

Phone Number

Email

Address

Cultural Considerations - Need to add detail for every option!

Current or Previous Provider

Consent to Contact

Comments

CommentsIf "other" was selected, specify here

Interview Questions

Tell me about yourself/your person, what makes you/your person happyThis is a warm welcome and opportunity to get to know the person before diving into the questions below

What are your likes and dislikes?

What are your interests and hobbies?

What do they like doing at home/at school?

Do you have any Siblings and/or pets?

Preferred Communication Method

VerbalFormal signing (Auslan, Makaton)Gesture/informal signingCommunication device

How do I like to communicate with other? How can staff communicate with me? How would I like staff to communicate with me? Things I say or do and what does that means?

Preferred communication method 2 old

Behaviour Support Question

Do you/your person require any support in managing their feelings and emotions?

Does the person shout, hurt themselves or others? Can they cope in groups? Do they have a BSP or any restrictive medication?

Known triggers, frequency and duration, how can we best support your person during these times, do the strategies require any tools or aids

What strategies are currently used and are they effective?

Frequency of behaviour and triggers?

Do they have a Behaviour Support Practitioner?

Do they have a BSP (Behaviour Support Plan)?

Copy of BSP Requested

Do they have restrictive practices and/or medication?

Any safety concerns?Specifics of the safety concern and how its managed. Kitchens safety, road safety, animals, supervision needs, stranger danger awareness etc

Are you/is your person happy to stay with the group? Is there any potential concern of your person wandering away or leaving the group for any reason? If yes please provide details (What would be the potential reason for them leaving the group, how are they best supported and re -directed back to where it is safe etc)

Medication Question

Do you have any specialised health needs?Prompts – Respiratory, Diabetes, Epilepsy, Asthma, Trachea, PEG, Stoma, Catheter. DNR in place?

Provide details, if necessary

Do you take medication?

What do you take and when and is this regular or as a PRN.

Would you need medication administered at Onemda during the 9am-3pm program time or during the Xtend program?

How does the person take their medication (with food, etc) What medication do you take, what time of the day, how does the person take their medication (eg, with food, dissolved, through PEG, crushed, independent)

Do you require any specialised staff training?Prompts – Behaviour Support, Medical, PEG, Trachea, Stoma, Manual Handling, Personal care.

What is the training for? Who will be delivering it?

Do you have any allergies?Prompts – Food, Grass, Dust, Sunscreen.

How severe is it? Do you carry an epi-pen?

Mobility Question

Do you need help with moving around?Prompts – Uneven surfaces, getting up and down from chairs, use of aids equipment, falls risk.

What supports do you require? Do you utilise mobility aids and equipment, do you have a mobility or movement plan? Do you have any vision or depth perception concerns that affect your mobility?which are helpful are navigating stairs, uneven surfaces, getting up and down from chairs or the floor, lifts and escalators.

Have you had any falls in the past 6 months? Do you use a walking aid? If yes, recommend referral for PT Assessment

Personal Care Question

Do you need help with personal care, washing, dressing, etc Prompts – how many people required to assist with personal care? Frequency. Estimate of how long changes would take.

Please expand on the specific support requiredDo you use any equipment or aids, do you have any specialised care plans or specific requests

- Frequency if require timely tasks, i.e. showers - Skin conditions that require creams, etcIf yes, recommend referral for PT Assessment

Do you need help with meals and drinks?Prompts – PEG, mealtime profile, thickened drinks, supervision, support to cut up meals, pour drinks, dietary needs.

- Mealtime profile specifics, supervision supports e.g. 1:1 - type of PEG and how long, training required training - Mealtime plan from a Speech PathologistPlease expand on the specific support required

Do you enjoy working as part of a group?Prompts – reinforce Onemda’s model. Any concerns raised? Consider impact on others.

Comments

Do you have any requirements for travel as a part of your program?Prompts – traveling on a bus with other participants, using a front seat or not. Buckle guards.

Comments

Group Services

What programs do you enjoy? Anything specific you don't enjoy, list below.Mention POS and how it works.

Comments / Goals

What does a good day look like for you/them?

What do you/they need our staff to know so that we can support you/them to have a successful day.

Does the person require a break-out, quiet area? Do they benefit from structure? Will they need regular breaks from a group setting? Do they require visual schedules or prompts. Do they have routines that need to be followed?

Transition program supports and expectationswhat you/your person need from Onemda to ensure a positive and successful transition? Do you have an idea of what their transition program would look like? Eg. number of sessions, early commencement, therapy transition, slow transition, are there support workers or school staff available to support.

Decision to Proceed

Campus Location *

Campus Coordinator Name

Campus Coordinator Email

Therapy

NDIS number

NDIS dates

Funder arrangements

Funder arrangement Other

NDIS Goals

Therapy Specific Goals

Therapy Funding Amount ($ or Hours)

Start Therapy Immediately?

When to start therapy

Are they already accessing therapy

What goals are they already working on

Comments

Decision to proceed Therapy

BSP Review

BSP Requested

BSP Requested Date

BSP Recevied

BSP Received Date

BSP Reviewed

BSP Reviewed Date

BSP Reviewed by

Outcome of review

BSP Decision to proceed

SCHOOL/SERVICE PROVIDER OBSERVATION VISIT

Is an observation site visit required

Reason for no visit

Is a discussion for more information required

Reason for no more information

Name of school or service provider

Contact Person

Plan nominee has provided consent for the visit or discussion to take place

Date or time of site visit or discussion(if it was a discussion only how was this undertaken – phone, email, online, on site at our office

Information Gathered

Decision to proceed

COME & TRY OBSERVATION ( To be completed by Campus Co-ordinator)

Staff member supporting the participant

Participant's support person

What program(s) did the participant take part in*(similar question section above)

Did the participant appear to enjoy the activities? How was this observed? *(similar question section above)

Did the the participant require any individualised supports? How was this demonstrated?

Participant Interview - to be completed at the end of Come & Try session with Campus Coordinator.

Have you had a good day?

What was the best part of your day?

What was your favourite program/activity?

Would you like to come back to Onemda?

Is there anything we could have done differently?

Other comments

Rate Your Day

Intake Team Member *

Intake Team Email

Provide student/participant with an Onemda goody bag and contact family/Carer with feedback re the above.

RISK ASSESSMENT ( To be completed by Intake Team)

Risk Screening Determination

Any specialised training, allergies, BoC or Manual Handling needs, specific mealtime

assistance to be flagged with GM Services as to whether to proceed.

Decision

Offer

PLACEMENT OFFER - Documentation Required (To be collected by intake team)

Documents Required before proceeding to Sign up Phase.

Once documents received, these MUST be uploaded to Penelope and Sign-Up page to be completed.

Specify Other Documentation (if necessary)

Save and Complete Later