Section 1 Personal Information
1.1
Name
Address:
postal code
Place
Telephone No:
Mobile No:
1.2
Date of Birth
Bovenkant formulier
Date/period of completion:Compiled by:
In consultation with:
This form should be used for the purpose of compiling the information gathered through the Person Centred Planning and Vocational Profiling process for recording in the individual’s file. It is intended to be used as a tool in itself.
Section 2 Circle of support
Inside – evident/ regular supports.
Outside – occasional supports
Mother: / Father:
Address: / Address:
postal code / postal code
place / place
Telephone No: / Telephone No:
Mobile No: / Mobile No:
3.2 Siblings:
Name: / Name:
Name: / Name:
Name: / Name:
Name: / Name:
3.3 Relevant other family:
3.4 Family support available:
Section 4 Living Arrangements Prompts
4.1 Current Living arrangements Where living
Whith whom ?
Own room?
Access to facilities
Transport
4.2 Current Living arrangements Where living
Respite
How often?
Where ?
4.3 Past residential arrangements
Where
For how long
Dates
4.4 Description of typical routines at home Specific chores
Daily chores
Cooking/cleaning
Tell me about your day
Leisure
Hobbies
Interests
4.5 Facilities in the home neighbourhood
Playing fields/parks
Shops
Factories
Leisure facilities
swimming pool
how often do you go out
meeting others
Section 5 Personal Sills and Qualifications
5.1 Personal skills (including limits and support needs)
Time keeping
Using support
available.
Set up situations to observe skills
Test outside centre
5.2 Social and Communication Skills (including limits and support needs )
Set up situations to observe skills. Test Outside centre.
conversation
ability to take criticism
politeness
to ask for help
getting on with others
5.3 Community Functioning Skills (including limits and support needs)
Set up situations to needs , observe skills. Test outside centre.
crossing road
using shops
using public transport
Etc
5.4 Recreation/Leisure Skills (including limits and support needs)
use of free time
sports
involvement in clubs
etc.
5.5 Domestic/Living Skills (including limits and support needs)
take care of home
cleaning
cooking
budget
etc
5.6 Academic Skills (including limits and support needs) Practical examples (reading, writing, maths, money, memory, concentration) of reading/writing
Money skills
Remembering
Consistency of skills
Test out skills
5.7 General Coping Skills (including limits and support needs)
What would you do if somebody had an argument with you?
What would you do if you had an accident?
Concern/fears
5.8 Motor/Mobility Skills (including limits and support needs)
Set up situations to observe skills . Test outside centre.
dexterity
walking
climbing stairs
etc
5.9 Medical issues that may effect activities
Current medication Recent medication or illness Any “turns” or blackouts
epilepsy
heart condition
diabetes
medication
etc.
Section 6 Education/Training and Previous Placements
Courses Completed / Start Date / Finish Date / Comments
Work Experience/ Job Placements / Start Date / Finish Date / Comments
Section 7 Interests and Preferences Prompts
7.1 Activities most enjoyed
In centre
At home
7.2 Social situations liked best
Disco
Pub
Movies
Sport/Football
Fishing
7.3 Friends and social group
Names of people
Names of groups
organisations
7.4 Description of typical weekday leisure/recreational activities
What do you enjoy doing?
How often?
7.5 Description of typical weekend leisure/ recreational activities
What do you do at weekends that you don’t do during the week?
Who do you go with?
Section 8 Learning and Performance Characteristics
8.1 Preferred learning environments?
8.2 Preferred/ most suitable instructional strategies
8.3 Supports typically required for learning and participation in activities
8.4 Environments/ strategies which should be avoided
8.5 Particular habits/ routines which may effect learning/ participation in activities
8.6 Other issues
Section 9 Work Experience Information
9.1 Informal work performed at home
Jobs you sometimes do around the house
Helping mother/father out
9.2 Formal chores at home
Jobs you do every day
Tidy room/make bed
Cooking
Consistency in doing these jobs
9.3 Informal jobs performed for others
Jobs done for neighbours/
relatives/
friends
9.4 Work experiences best liked/ least liked
List work placements What did you like?
Why?
What did you not like?
Why?
9.5 Observations of the types of work the applicant likes to do:
Views of others who know the person
9.6 Type of work Parent/ Guardian feels is appropriate:
Any areas of work parents are not keen on
Why?
9.7 Type of work others feel is appropriate
Why?
What influenced this decision?
Section 10 Work preferences
10.1 Expectations about work in general Money (why work etc.)
Independence
Choice
Self Esteem
10.2 Preferred career (dream job)
If you could have any job you wanted Why that job?
What would that job involve?
10.3 Preferred work tasks
Variety
Constant
Repetitive
Manual
Refer to preference
List/ job match
Analysis
10.4 Preferred work environment
With people
Indoor/outdoor
Noisy/quiet
Busy/steady work
Shop/pub/office
Factory/garden
10.5 Expectations with regard to work conditions (pay, hours, days )
Mon-Fri (9 – 5 )
Weekend/evening
Part/flexi time
Holidays
Pays- Disability
Allowance
10.6 Preferred work location
Near home
Convenience
Transport-public
Lifts
10.7 Preferred support
Male/Female
On/Off site
Regular/occasional
Section 11 Supports available related to Work
11.1 Potential Support People with regard to getting and keeping a job (finding a job, transport etc.)
Mother/Father
Brothers/sisters
Aunts/uncles
Cousins
Neighbours
Friends
Staff
11.2 Sources of Potential Jobs Family business
(Company names and contact people)
Family contacts
Neighbouring
Companies
Section 12 Job Match Profile
Personal Profile / Job AlysisJob type
Indoor/Outdoor
Work Environment/Ambience
Social Environment/Ambience
Work Place Culture
Work Days
Work Hours
Travel Distance/Transport
Dexterity Skills
Mobility Skills
Communication Skills
Literacy Skills
Sight
Stamina
Hearing
Speed/Pace of Work
Accuracy/Quality
Concentration
Number of Co-workers
Male/Female Co Workers
Clothing/Grooming
Variety of Work
Complexity of Tasks
Health Factors
Safety Factors
Social Opportunities
Wages and Benefits
Career Dev. Opportunities
In Company Supports
Section 13 Current Benefits and Allowances
13.1 Social Welfare payments
Name of benefit
weekly amount
how payment is made
13.2 Additional Benefits
travel
pass
rent
allowance
13.3 Other Allowances/Income which may be effected by work
Trust fund
KARE
Allowance
This form is a sample which is used by one of the organisations in Ireland
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