Application For Supported Independent Living

Please read before completion

About this application form

This form is to be used by Civic for people wishing to apply for Supported Independent Living.

Who can apply for Supported Independent Living (SIL)?

• A person who is a NDIS participant and has a current NDIS plan.

• A person who is wanting to transition from their current accommodation and transition to Supported Independent Living.

• A person who is deemed suitable by NDIA to reside in Supported Independent Living.

Important information for applicants/support network

• Please complete all sections of this form. It is essential that ALL information is as detailed and accurate as possible to fully assess the support requirements of the applicant.

• The application should be accompanied by documentation that supports statements about the applicant’s support needs, for example behaviour support plans, health care plans and personal care protocols.

• Once form is completed, including the signed consent page, please attach any supporting documentation and submit to enquiries@civic.org.au via email wherever possible. If this is not possible, please contact the Customer Experience Team directly to discuss submission.

• A member of the Customer Experience Team may contact the person nominated on the form in (Section 3) if further information is required to support the application.

• Insufficient or inaccurate information may impact on the offer of services, including withdrawal of offers made on the basis of inaccurate information provided in the application form.

• Applicants will be contacted by our Customer Experience Team to advise you of the progress of your application and to advise of any necessity to further assess the suitability of the applicant.

• Contact the Customer Experience Team (1300 692 484) if you have any questions regarding this form.

SECTION 1: Applicant Information
First Name*
Surname*
Gender*
- Male
- Female
Date Of Birth*
Address/Suburb/Postcode*
Daytime Phone
Mobile Phone*
Email*
Primary Disability*
Other Disability
Preferred Language
Interpreter?
- Yes
- No
Indigenous Status
Aboriginal & Torres Strait Islander?
- Yes
- No
Legal or Financial Guardian
- Yes
- No
NDIS Participant Number*
SECTION 2: Person Completing This Form (If Other Than The Applicant)
First Name
Surname
Relationship To Person Requiring Support
Organisation
Daytime Phone
Mobile Phone
Email
SECTION 3: Nominated Person For Further Clarification/Information

Note: Member Of The Customer Experience Team May Contact The Person Below If Further Information Is Required
First Name
Surname
Relationship To Person Requiring Support
Organisation
Daytime Phone
Mobile Phone
Email
SECTION 4: Emergency Contact
First Name
Surname
Relationship To Person Requiring Support
Organisation
Daytime Phone
Mobile Phone
Email
SECTION 5: NDIS Information
National Disability Insurance Scheme (NDIS) Plan Status
Plan Start Date*
Plan End Date*
Payment Method*
- Plan Managed
- Self-Managed Plan
- NDIS Managed Plan
Plan Manager Details (If Applicable)
Name Of Contact
Organisation Name
Phone Number
Email
Support Co-ordinator Details (If Applicable)
Name Of Co-ordinator
Organisation Name
Phone Number
Email
My NDIS Goals
SECTION 6: Housing History
Are you currently living in a Supported Independent Living placement?
- Yes
- No
Details (if yes)
If yes why do you want to leave?
If no what is your housing history? (include short-term placements)
Date Housing Why did this not work
Why do you want to move into Supported Independent Living?
SECTION 7: Understanding Your Support Needs
Communication
How Do You Prefer To Communicate
- Verbally
- Non-Verbal/Vocalize
- Auslan
- Point/Gesture
- Makaton
- IPad
- Combination of Auslan/Makaton
- PECS
Do you engage with technology or family members to communicate on your behalf?
How do you express your feelings and understand others?
If you are non-verbal, how do you make your needs known?
Have you had a speech assessment?
- Yes (If yes, please attach)
- No
If yes — who completed the assessment?
Date
Behaviour Support

Do you require support due to any of the following behaviours?
Absconding/leaving the residence
- Current
- Historical
Verbal asssault/aggression
- Current
- Historical
Physical asssault/aggression
- Current
- Historical
Self harm/self-injurious behaviour
- Current
- Historical
Enter other person space/room (without consent)
- Current
- Historical
Property damage
- Current
- Historical
PICA
- Current
- Historical
Obsessive Compulsive Routines
- Current
- Historical
Sexualised Behaviours
Risk to self
- Current
- Historical
Risk to others
- Current
- Historical
Fetish Behaviours
Risk to self
- Current
- Historical
Risk to others
- Current
- Historical
- I have no behaviours of concern that require specific support
Other
Offending Behaviours
Are there any outstanding court orders or injunctions against you?
- Yes
- No
Details (If Yes)
Have you experienced any periods of detention?
- Yes
- No
Details (If Yes)
Have you offended family members/others and this has not been reported?
- Yes
- No
Details (If Yes)
Support Plans
Do you have any of the following support plans/protocols — if yes please attach these plans to this form
- Behaviour Support Plan (Restrictive Practices)
- Epilepsy Management Plan
- Health Management Plan
- Diabetes Management Plan
- Mental Health Plan
- Asthma Management Plan
- Nutrition and Swallowing
- PEEP
- Person centered plan
- Personal Care protocol
- MHSP/ Multi element support plan
- Mealtime management plan
Equipment
Do you use any equipment? (eg. hoist, walking frame, wheel chair, commode, hearing aids, glasses, shower chair.)
- Yes
- No
Details (If Yes)
Do you need assistance using any equipment above?
- Yes
- No
Details (If Yes)
Will staff require training in its use?
- Yes
- No
Details (If Yes)
Daily Living

Please indicate the level of support required by the person to undertake the following tasks. Please attach any relevant assessments and or reports.

No help — you are fully independent. You need no help physically to complete the task

No help but uses aids — with aids, you can complete the task by yourself with no help

Prompting — you need reminders or prompting to do the task

Some support — you need prompting or modelling, and some hand-over-hand support

Full physical support— you cannot complete the task/activity without full physical support
Showering/bathing
- No Help
- No Help But Aids Used
- Prompting
- Some Support
- Full Physical Support
Describe:
Grooming
- No Help
- No Help But Aids Used
- Prompting
- Some Support
- Full Physical Support
Describe:
Dressing
- No Help
- No Help But Aids Used
- Prompting
- Some Support
- Full Physical Support
Describe:
Toileting
- No Help
- No Help But Aids Used
- Prompting
- Some Support
- Full Physical Support
Describe:
Eating/swallowing
- No Help
- No Help But Aids Used
- Prompting
- Some Support
- Full Physical Support
Describe:
Domestic Tasks
- No Help
- No Help But Aids Used
- Prompting
- Some Support
- Full Physical Support
Describe:
Using Money
- No Help
- No Help But Aids Used
- Prompting
- Some Support
- Full Physical Support
Describe:
Decision Making
- No Help
- No Help But Aids Used
- Prompting
- Some Support
- Full Physical Support
Describe:
Taking Medication
- No Help
- No Help But Aids Used
- Prompting
- Some Support
- Full Physical Support
Describe:
Mobility
- No Help
- No Help But Aids Used
- Prompting
- Some Support
- Full Physical Support
Describe:
SECTION 8: Additional Information For Intake
Day And Night Support

Please attach any relevant assessments and or reports.
DAY
- I require supervision or support at all times during the day
- I require supervision or support during active times(for example when getting ready, at meal times, preparing for bed)
Complete below section regarding night assistance.
NIGHT*
- Most of the time I do not need assistance when I am sleeping
- I need assistance during sleeping hours -- complete below section regarding night assistance
Active night support is needed for: (Select ALL that apply to you)*
- Peg Feeding
- Pressure Care
- Toileting
- Behaviour
- Unsettled
- Repositioning
- Seizure/Medical
Other
During the night, how long do you usually need support for?*
- Less than 30 min
- 30 min—1 hour
- 1—2 hours
- 2+ hours
Health
Do you have any ongoing health, mental health or medical issues? If so, please describe your condition and how this affects your life and your support needs. Please attach any relevant assessments and or reports.
- Yes
- No
Details (If Yes) - (For example epilepsy, diabetes, allergies, vision impairment)
Do you attend regular health appointments? If so, what are your appointments for, how often do you attend and where do you go? Does anyone usually go with you? Do you need support to attend appointments?
- Yes
- No
Details (If Yes)
Do you take medications or other treatments? If so, please provide details of your medication and treatment plan.
- Yes
- No
Details (If Yes)
Do you take any medication classed as a chemical constraint?
- Yes
- No
Please Name
Do you have any allergies?
- Yes
- No
Details (If Yes)
Do you have an special dietary requirements?
- Yes
- No
Details (If Yes)
If yes — who completed the plan?
Date
Do you have a recent (within 3 months?) occupational therapy report? If yes, please attach.
- Yes
- No
Details (If Yes)
If yes — who completed the plan?
Date
Getting Around
Please refer to any relevant assessments and or reports. Do you need help to get around your community? If so, describe the assistance you need (eg: help with steps, uneven surfaces or getting into vehicles).
- Yes
- No
Details (If Yes)
When you are out in the community as part of a group, what support do you need?
- 1:1
- 1:2
- 1:3
- 1:4
If 1:1 please give details
What mode of transport do you mainly use to travel to and from places? Tick if you have the following:
- Annual Travel Ticket
- Concession Card
- Opal Card
- Family/People I Know
- Taxi Card
- Service Provider
Other (Please Describe):
Do you need help to use public transport, taxis and other transportation? If yes, please give details
- Yes
- No
Details (If Yes)
When do you require transport?
Vocational
What do you do during the daytime, Monday to Friday? Do you participant in any day time activities, workplace, education or training, please provide the names and addresses of the services you attend.
Are there any day time activities you wish to explore or challenge in the future?
Please complete your daily schedule below. Include times, places and activities you regularly attend.
Monday*
Wake-up Leave time AM PM Arrival time Bedtime
Tuesday*
Wake-up Leave time AM PM Arrival time Bedtime
Wednesday*
Wake-up Leave time AM PM Arrival time Bedtime
Thursday*
Wake-up Leave time AM PM Arrival time Bedtime
Friday*
Wake-up Leave time AM PM Arrival time Bedtime
Saturday*
Wake-up Leave time AM PM Arrival time Bedtime
Sunday*
Wake-up Leave time AM PM Arrival time Bedtime
Other Information
Is there any other information you would like to add?
SECTION 9: Consent and Declaration
You or your authorised representative* must provide consent for the information provided in the Civic Services application (and requested assessments and reports) to be used in the following ways:

• To create a file (electronic and/or paper).

• For assessment purposes.

• To be shared with direct support workers and their managers for the purposes of providing appropriate support to the applicant.

• For statistical reporting (information is de-identified).

*Your representative could 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.
Written Consent & Declaration

I have been informed and consent to the use of information in the application for the Civic Services that I am applying for. I understand that this information may be used to create a file (electronic or paper). 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 Civic Services and the information given on this form is true and correct to the best of my knowledge.
Signed
Date
Name
If signed by a representative, please state your relationship to the applicant:
Relationship
Verbal Consent

Only to be used where it is not practicable to obtain written 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.
Verbal consent provided by
Date
Person/representative’s name
Relationship
Civic Staff Member
Please upload any documents referenced in your application, e.g. OT report. Please ensure documents are recent, ideally dated within the past 18 months
Drop files here or

Max. file size: 256 MB.
Name
This field is for validation purposes and should be left unchanged.

64784

SECTION 1: Applicant Information

Indigenous Status

SECTION 2: Person Completing This Form (If Other Than The Applicant)

SECTION 3: Nominated Person For Further Clarification/Information

SECTION 4: Emergency Contact

SECTION 5: NDIS Information

National Disability Insurance Scheme (NDIS) Plan Status

Plan Manager Details (If Applicable)

Support Co-ordinator Details (If Applicable)

SECTION 6: Housing History

SECTION 7: Understanding Your Support Needs

Communication

Behaviour Support

Sexualised Behaviours

Fetish Behaviours

Offending Behaviours

Support Plans

Equipment

Daily Living

SECTION 8: Additional Information For Intake

Day And Night Support

Complete below section regarding night assistance.

Health

Getting Around

Vocational

Other Information

SECTION 9: Consent and Declaration

Written Consent & Declaration

Verbal Consent

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