Request for Service

Community Learning and Living is a therapy service team that works with adults with disabilities. Our team includes occupational therapists, physiotherapists, speech pathologists, mobility and public transport trainers, therapy support and administration staff. We work with the individual’s goals of communication, physical mobility and modified living solutions.

FUNDING STREAMS

Please phone 9312 8318 if you require further information

National Disability Insurance Scheme Current and future NDIS participants

Department Health and Human Services DHHS eligibility criteria applies

Fee For Service

Service Request for: / First Name: / Last name::
Primary Diagnosis (e.g. Cerebral Palsy, ABI):

♦ A Medical Certificate may be required ♦

♦ If the client has a Behaviour Support Plan, please attach a copy ♦

Disability / Impairment (Tick one or more)

Physical Intellectual Neurological Mental Health Other (e.g. Sensory)

(Please specify the Disability/Impairment)

Date of birth (or age): / Gender: Male Female
Address:
Suburb: / Postcode:
Home phone: / Email:
Work phone: / TTY:
Mobile phone: / Fax:

Service Requested by:

Self
Other / If Other, please complete the contact details below:
Relationship to service user: (e.g. Worker, Parent, Friend)
Name: / First Name: / Last name::
Mobile phone: / Fax:
Position title/Department:
Organisation:
Work phone: / Email:
Mobile phone: / Fax:

Does the service user agree with this request? Yes No

If No, what is the reason?
Signed: / Date:

About the Service User

What is your country of birth?

Are you of Aboriginal or Torres Strait Islander (TSI) origin?

Aboriginal but not TSI origin TSI but not Aboriginal origin

Both Aboriginal and TSI origin Neither Aboriginal or TSI origin

Do you identify as having a CALD background? No Yes

In the Australian context, individuals from a CALD background are those who identify as having a specific cultural or linguist affiliation by virtue of their place of birth, ancestry, ethnic origin, religion, preferred language, language(s) spoken at home, or because of their parents’ identification on a similar basis (Department of Human Services Multicultural Strategy Unit, 2002)

Do you require us to provide an interpreter? No Yes / Language:
What contact method is best for you? e.g. phone, email, mobile
Do you use a communication aid? No Yes / Type:
Which communication method is best for you? e.g. verbal, Auslan, communication device:

Do you usually live alone or with others?

Lives alone Lives with family Lives with others

Do you receive a Funding Package?

Yes e.g. ISP, Linkages, Respite, One-off, that is, short and long term funding and/or packages

Specify:

No

Unsure

What services and activities are you currently receiving?

Are you seeing a Case Manager, Therapist, Doctor, Social Worker etc.?

Tell us what services you are requesting and why – refer to page 4 for a list of services we offer noting that services offered are needs based, short term and goal orientated. If requesting more than one service, please list in priority order.

NOTE: Referrals related to recent hospitalisations need to be made to your local Community Health Service in the first instance.

Please return form to:

  • Via Email:
  • Via Post:Community Learning and Living,

1/50 Wheatsheaf Road, Glenroy MELBOURNE 3046

  • Via Fax: 03 9306 2449

We will be in touch with you about the service you have requested but if you have not had an acknowledgment after one month please contact Community Learning and Living regarding your requeston 9312 8318

What common services do we provide?

Assessment and Prescription (Equipment)
  • Equipment assessments/prescriptions
  • Funding applications for prescribed equipment
  • Training in equipment use
  • Minor modification/repair/fabrication to equipment
  • Therapy aid support
/ Physiotherapy
Occupational Therapy
Speech Pathology
Communication and Mealtime Assistance
  • Assessment of swallowing
  • Mealtime support and communication training
  • Communication skills assessment, training and programs
  • Augmentative and Alternative Communication (AAC) prescription and training
/ Speech Pathology
Home Modifications and Assessment
  • Home modification assessments
  • Funding applications for home modifications
/ Occupational Therapy
Physiotherapy – Individuals
  • Individual therapy to improve motor control and posture
  • Individual therapy for pain and spasticity management
  • Individual exercise programs including Home based, Community gym and Hydrotherapy
/ Physiotherapy
Physical Health and Well-Being – Individuals
  • Specific skill development in daily living
  • Newborn care for parents with a disability
  • OH&S assessments
  • Mobility assessment and prescription
  • Falls, balance and safety
  • Pressure care assessments
  • Ergonomic assessments
/ Physiotherapy
and
Occupational Therapy
Fee for Service
  • Independent Living Skills Assessment
  • Manual Handling Profiles
  • Manual Handling Training
  • Sensory Assessments
/
  • Speech Pathology assessments and training
  • Physiotherapy assessments, therapy and outcome reports
  • Mobility and Public Transport assessment
/ Occupational Therapy
Speech Pathology
Physiotherapy
Mobility and Public Transport Training
NDIA - Any of the above services

Pre-Visit Risk Assessment

Alerts:
Customer Name: / Address:
Date: / Review Date:
Telephone Number Confirmed: Yes No Do not commence visits until confirmed
Carer Name (if relevant): / Carers Ph No (if relevant):
Staff Signature: / Staff Name:
Manager Signature: / Manager Name:
Property Access Information: eg. Parking, adequacy of lighting
Environment Assessment / Comments
Has any aggression from the customer/other occupants of the house been reported? / Yes
No
Does the customer/other occupant of the house have a past psychiatric history? / Yes
No
Does the customer/other occupant of the house have alcohol/drug abuse issues? / Yes
No
Does the customer/other occupant of the house smoke within the home? / Yes
No
Does the mobile phone work in the area? / Yes
No
Animals / Comments
Are there any animals that have access to that part of the garden where staff will enter? / Yes
No
Other Persons
List occupants and their relationship to the customer
Occupant Name: / Relatonship to customer:
Comment on any risks associated with other household occupants
List specific instructions for addressing these risks
Immediate neighbourhood
Detail any aspects of the immediate neighbourhood that may be considered a security risk
Additional relevant information
Detail any further information relating to possible risk for staff making home visits (include detail of which other agencies have been contacted for information)
Summary of Risk (include details of strategies for addressing risks if possible)
Outcome of Assessment
Home Visit Alone Two person Home Visit No Home Visit allowed
Rationale:
Name:
Manager Approval
Name:
Signature: Date:
Comments Following Visit / Name / Date
This document is uncontrolled when printed, please refer to the Policies and Procedures Library for current controlled version
Policy Index: Customer/Community Learning ＆Living / Effective Date: 4/07/2016 (v8)
Responsible Manager: Kim Magee / Page 1 of 7