New Referral - Wave Care

Do you give consent to share this form with your Support Network, other providers. and Relevant Government Agencies?

Yes No

Describe the Support Required

Is this Home easy to Locate?

Yes No

Is Onsite / Street Parking Available for Support Worker's Car

Yes No

Are any Gates or Doorways Difficult to use or Access

Yes No

At night, is the House Entrance Hard to Find

Yes No

Are there any Slip, Trip or Failing Hazards Outside the Home

Yes No

Is the Home Wheelchair Accessible

Yes No

Will the Support Worker be required to use any Electric Appliances

Yes No

In case of any emergency in the home, please describe the emergency procedure for the support worker to follow. Please consider any special procedures, nearest exits and emergency meeting points

Is there anything else you would like to share about the home

NOTE:

It is the participant's responsibility to ensure certain safety requirements

Electrical appliances and power cords are in good working order.
Power cords are attached to power boards and power sockets, and not double adapters
The house is fitted with a safety switch
Support workers will not be exposed to cigarette smoke in the home

Are there any places, situations or specific irritants that should be avoided

Please provide details on how to manage this risk. Describe in detail if there is any way to avoid

If something goes wrong in the community, are there any specific emergency instructions for the support worker

Is there a risk that participant may abscond

Yes No

What type of transport participant will use? Please tick the relevant.

Are there any specific risks associated with transport

Do you give consent for the support worker to proactively support you in attending medical, and allied health services?

Yes No

Wave Care will take reasonable efforts to work with the participant in selecting the preferred support worker

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We Take Your Referral Very Seriously

Participant Referral Support Plan

NOTE:

Wave Care will take reasonable efforts to work with the participant in selecting the preferred support worker

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