SDA Application Form

This form is to be used for to apply for a position in specialist disability accommodation (SDA). Please provide the information in each section below for apply.

Step 1 of 7

Application property information

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Application Date

Day

Month

Year

Preferred property (if known)

Applicant details

Customer name

Address

Suburb

Postcode

State

Phone (include area code)

Gender identity

Date of birth

Day

Month

Year

Primary diagnosis

Secondary diagnoses

Do you identify as Aboriginal or Torres Strait Islander?

Yes, Aboriginal

Yes, Torres Strait Islander

Yes, both Aboriginal and Torres Strait Islander

What is your preferred language?

Do you need an interpreter?

Yes

NDIS

Are you an NDIS participant?

Yes

Do you have an NDIS plan?

Yes

NDIS participant number

If no, please explain why? (e.g. plan review, need SDA eligibility confirmation)

Is Specialist Disability Accommodation eligibility confirmed in your approved NDIS plan?

Yes

If yes, please specify the SDA Building Type

If yes, please specify the SDA Design Category

If yes, please provide the SDA funding amount approved in the plan

*If no, you will need to request a plan review
or seek your SDA eligibility confirmation urgently

Do you receive the Disability Support Pension?

Yes

Do you receive the Commonwealth Rental Assistance?

Yes

If yes, amount per fortnight

Support coordinator

Organisation

Phone (include area code)

Primary contact person

Contact person name

Phone (include area code)

Relationship or Organisation

Address

Suburb

Postcode

State

Person completing this form

Completing person name

Phone (include area code)

Relationship or Organisation

Address

Suburb

Postcode

State

Contact person for additional information

Contact person name

Phone (include area code)

Relationship or Organisation

Address

Suburb

Postcode

State

Your current housing and living situation

Do any of the following apply to you?

I am currently homeless or living in temporary or interim accommodation

There are risk factors for me or my family or current carer (such as acts of harm or violence resulting in injury)

My family or current carer is ageing or has health concerns and can no longer offer me the support I need

Please describe your current living situation

With family

Living independently

Another SDA

Supported residential services (SRS)

Nursing home

Rehabilitation

Hospital

Other

Other (please specify below)

Please describe your previous living arrangements over the past 5 years (if different from above)

About you

Please tell us about your personality:

Please tell us about your hobbies and interests:

Your current support needs

Current support

How do other people currently assist with your support needs?

Do you have any formal support from service providers? What informal support do you have from family and friends?

Person or agency name (e.g. my parents)

Description of support provided (e.g. physical assistance with toileting)

Communication

How do you prefer to communicate? Please select all preferences.

Verbally

Auslan

Makaton

Non-verbally with vocalisations

Point and gesture

iPad / Tablet

PECS

Other

Other (please specify below)

Have you had a communication assessment?

Yes

If yes, who completed this assessment?

Date of assessment

Day

Month

Year

How do you express your feelings?

How do you understand others?

If you communicate non-verbally, how do you make your needs known?

Daily living skills

Please tell us about the level of support you need to do the following activities
• No help means you are fully independent and need no help from another person to complete the activity
• Uses aids means you don’t need help from another person, and you use an aid to do the activity by yourself
• Prompting means you need another person to give you reminders during the activity
• Some support means you need another person to prompt you, model the activity and give a you some hands-on support • Full support means you need another person to physically help you do the activity

Support required

Showering & bathing

No help

Uses aids

Prompting

Some support

Full support

Please describe the support you need with this activity

Grooming

No help

Uses aids

Prompting

Some support

Full support

Please describe the support you need with this activity

Dressing

No help

Uses aids

Prompting

Some support

Full support

Please describe the support you need with this activity

Toileting

No help

Uses aids

Prompting

Some support

Full support

Please describe the support you need with this activity

Eating

No help

Uses aids

Prompting

Some support

Full support

Please describe the support you need with this activity

Cooking

No help

Uses aids

Prompting

Some support

Full support

Please describe the support you need with this activity

Domestic activities

No help

Uses aids

Prompting

Some support

Full support

Please describe the support you need with this activity

Using money

No help

Uses aids

Prompting

Some support

Full support

Please describe the support you need with this activity

Decision making

No help

Uses aids

Prompting

Some support

Full support

Please describe the support you need with this activity

Taking medication

No help

Uses aids

Prompting

Some support

Full support

Please describe the support you need with this activity

Mobility

No help

Uses aids

Prompting

Some support

Full support

Please describe the support you need with this activity

Equipment

Do you use any equipment? This includes things like a hoist, walking frame, wheelchair, a commode, hearing aids and glasses

Yes

Please describe the equipment you use:

If you use equipment, do you need assistance to use the equipment?

Yes

Please describe the equipment you use:

If you need assistance to use equipment, will staff require specific training to help you use the equipment?

Yes

Please describe the equipment you use:

Day and night supports

Which of the following best describes the support you need during the day?

I need support or supervision at all times during the day

I need support or supervision during active times of the day, such as getting ready, meals and bed time

How long can you be on your own for?

Not at all

1 to 2 hours

3 hours or more

Which of the following best describes the support you need at night?

Most of the time, I do not need support when I am sleeping

I need support during sleeping

Which of the following do you need support with at night?

PEG nutrition

Pressure care or repositioning

Toileting

Settling

Behaviour

Seizures or medical needs

Other

Other please specify below

How many nights per week do you usually need night support?

1 or 2

2 to 3

3 to 4

5 and over

During nights, how long do you usually need support for?

Less than 30 minutes

30 minutes to 1 hour

1 to 2 hours

2 hours or more

Health

Do you have any ongoing health, mental health or medical issues?

Yes

If yes, please describe your condition(s) and how this affects your life and your support needs:

Do you have a chronic disease management plan, a mental health care plan or any other medical plans?

Yes

If yes, please attach a copy of any relevant health care plans when emailing this form.

Drop files here or

Max. file size: 25 MB.

Do you take any medications or have any treatments?

Yes

If yes, please attach details of your medications and any treatment plans when emailing this form.

Drop files here or

Max. file size: 25 MB.

Do you smoke?

Yes

Do you attend any regular health appointments?

Yes

If yes, please list what each appointment is for, who it is with when it occurs and where it is held, if anyone usually attends with you and if you need support to attend:

Do you have a recent occupational therapy report?

Yes

If yes, who completed this assessment?

Date

Day

Month

Year

Getting around

Do you need help to get around your community?

Yes

When you are out in the community, do you need any one-to-one support from a dedicated person?

Yes

What mode of transport do you mainly use to travel to and from places?

Do you have any of the following?

Annual travel ticket

Concession card

Taxi card

Other transport card

Other transport card (please specify)

Date

Day

Month

Year

Do you need help to use public transport, taxis and other transportation?

Yes

Please describe the help you need (e.g. help reading timetables, help planning a journey, getting into and out of vehicles):

Vocation

What do you do during the day on weekdays (Monday to Friday)?

If you regularly participate in any daytime activities, work, education or training, please provide the names and addresses of places you attend

Activity name

Monday

Activity name

Tuesday

Activity name

Wednesday

Activity name

Thursday

Activity name

Friday

Time leave

Monday

Time leave

Tuesday

Time leave

Wednesday

Time leave

Thursday

Time leave

Friday

Time home

Monday

Time home

Tuesday

Time home

Wednesday

Time home

Thursday

Time home

Friday

Travel method

Monday

Travel method

Tuesday

Travel method

Wednesday

Travel method

Thursday

Travel method

Friday

Support needs

Monday

Support needs

Tuesday

Support needs

Wednesday

Support needs

Thursday

Support needs

Friday

Do you do any regular activities on Saturdays or Sundays?

Yes

If yes, please provide details of your weekend activities, including names, location, start and finish times, travel methods and support needs:

Are there any daytime activities you would like to do or explore in the future?

Behaviour support

Do you have a recent history of behaviours for which you require support?

Yes

if yes, please check the box beside the behaviours below.

Property damage

Hurting others

Throwing objects

Sexualised behaviours

Verbal aggression

Self-harm or self injury

Refusing to take medications

Entering others’ rooms

Entering others’ personal space without consent

Absconding or leaving the residence without notice

Other behaviour (please specify)

Behaviour:

What is the purpose of the behaviour?

What triggers the behaviour?

How often does it occur?

What is the impact of the behaviour for you?

What works well to reduce the chance of the behaviour occurring?

Behaviour:

What is the purpose of the behaviour?

What triggers the behaviour?

How often does it occur?

What is the impact of the behaviour for you?

What works well to reduce the chance of the behaviour occurring?

Behaviour:

What is the purpose of the behaviour?

What triggers the behaviour?

How often does it occur?

What is the impact of the behaviour for you?

What works well to reduce the chance of the behaviour occurring?

Behaviour:

What is the purpose of the behaviour?

What triggers the behaviour?

How often does it occur?

What is the impact of the behaviour for you?

What works well to reduce the chance of the behaviour occurring?

Behaviour:

What is the purpose of the behaviour?

What triggers the behaviour?

How often does it occur?

What is the impact of the behaviour for you?

What works well to reduce the chance of the behaviour occurring?

Do you have a behaviour support plan?

Yes

If yes, please attach a copy of your plan when emailing this form

Drop files here or

Max. file size: 25 MB.

Do you have a human relations assessment?

Yes

If yes, who completed this assessment?

Date of assessment:

Day

Month

Year

Do you have a risk assessment for any of your behaviours or behaviour support needs? (e.g. fire or evacuation risk assessment)

Yes

If yes, who completed this assessment?

Date of assessment:

Day

Month

Year

Do you do anything else that other people living with you might find disruptive?

Yes

If yes, check the box beside the behaviours below.

Removing yourself from conversations or groups

Not reacting when spoken to

Alerting staff

Vocalising loudly when distressed

Ignoring directions from staff

Reacting physically

Vocalising loudly when distressed

Other behaviour

Other behaviour (please specify)

How would you react if someone you lived with acted in a way you found disruptive? For example, if a person disturbing a quiet environment, someone showing a lack of awareness of public versus private space, a housemate coming into your personal space.

Is there anything else you’d like to tell us about the behaviour supports you need?

Consent and declaration

• To create a file (electronic and/or paper) • To be seen by external agencies for an SDA vacancy • For statistical reporting (information is de-identified) * Your representative may be a primary carer, family member, advocate or an appointed guardian. A paid worker such as a case manager or support worker cannot be your representative.

I have been informed and consent to the use of information in the application for any Specialist Disability Accommodation dwelling vacancy that I am applying for. I understand that this information may be provided to external agencies for this purpose. I also understand that this consent allows for information in this application to be used for statistical reporting. I declare that I have provided all information relevant to my application for SDA and the information given on this form is true and correct to the best of my knowledge.

Name

Sign

Accepted file types: jpg, png, Max. file size: 5 MB.

Date

Day

Month

Year

If you are signing as a representative of the person applying for specialist disability accommodation, please provide your relationship to the person:

Verbal consent

I have discussed the purpose and disclosure of this information with the applicant or their representative and I am satisfied that they understand how the information will be used, and that they have provided informed consent to the submission of this application for support.

Name of person providing verbal consent

Relationship or Organisation

Date

Day

Month

Year