Vibe & Thrive: Adult Daily Support Program - Enrolment Form

CLIENT DETAILS

Client's First Name: *

Client's Last Name: *

Client's Date of Birth: *

Client's Age: *

Gender: *

MaleFemaleOther

Residential Address: *

What are the current living arrangements? *

Is the client verbal? *

YesNo

EMERGENCY CONTACTS

In the event of an unlikely emergency, NKB need to be able to reach a nominted emergency contact:

1 - Emergency Contact Name and Number: *

2 - Emergency Contact Name and Number: *

3 - Emergency Contact Name and Number:

TRANSPORT

Do you require pick-up/drop-off from your residence each day? *

YesNo

Do you consent for NKB staff to provide transport for community outings/excursions? *

YesNo

Do you get car/motion sickness?

YesNo

SUPPORT NEEDS

What days will you be attending? *

Meal Plan Mondays: 10am - 2pm - Learn to meal plan, shop for your groceries and prepare a meal for you to take home. Tournament Tuesdays: 10am - 12pm - Come along, make new friends and let the gaming begin! Toastie Tuesdays: 12pm - 2pm - Cook your own toasties and pastries to take home. Wellness Walk Wednesdays: 10am - 12pm - Get outdoors and move your body with a leisurely walk. Woodwork Wednesdays: 12pm - 2pm - Develop practical skills and get creative. Thrive to Grow Thursdays: 10am - 2pm - Learn to grow your own veggies and enjoy some gardening. Fun Day Fridays: 10am - 12pm - Get in touch with your creative side with some art and crafts. Fitness Fridays: 12pm - 2pm - Move your body while having fun!

What level of support do you require? *

One support worker to one adultTwo support workers to one adultOne support worker to two adults

Do you have additional needs or require extra support with day-to-day tasks? *

Do you require assistance with toileting? *

YesNo

Are there any activities that you cannot participate in? *

MEDICAL DETAILS

Do you have any allergies (and do you carry an EpiPen)?

Do you have any existing medical conditions or disabilities?If there is an action/management plan in place for an exisiting medical condition, please provide a copy to NKB immediately after completing this form.

Are you currently taking any medication?If yes, please list the name, frequency and dosage for each medication.

Guidelines around food and drink - Can you have soft drink/lollies or have any special dietary requirements?

SOCIAL/EMOTIONAL NEEDS

Do you have any specific fears or dislikes?

Do you have any particular triggers or situations that make you uncomfortable?

Do you have any sensory issues?

What are your interests / likes?

Do you have any suggestions for activities you want to do in the future?

Any other information you think would be helpful for the support worker to know:

BILLING INFORMATION

Fees:

For NDIS participants, the Vibe & Thrive Program will be charged as per the NDIS Price Guide.

For Private clients, the Vibe & Thrive Program will be charged at $125 per day for on-site activities (7 Rocla Road, Traralgon) or $150-$200 per day for excursions/community outings.

For all NDIS funded participants we ask that you please share a copy of your current NDIS plan with NKB, so a service agreement can be completed.

How will you be paying for the program? *

NDIS Plan ManagedNDIS Self ManagedPrivate/Self Funded

If NDIS Plan Managed, please include an email for invoices below:

CANCELLATION POLICY

Cancellation of Support:

If either party needs to cancel a booking, the party needing to cancel should provide 7 days notice. If the cancellation is not received in writing, 7 days prior, the participant will be invoiced for the full amount of hours the booking was scheduled for.

If cancelled due to illness, the whole scheduled booking will be invoiced, unless a doctors certificate is provided.

Please tick you understand and agree to the above cancellation policy. *

CONSENT

Do you consent for photos to be taken for marketing purposes? *

Yes No

Please tick: *

In the event of an emergency, NKB Supports can access appropriate medical care for myself/client, at my expense. I have read and understood this Enrolment Form. I agree to the above conditions for the service provided by NKB Supports and acknowledge that I have read all relevant information about our service as available on our website or on request.I give consent for my NKB Supports to discuss myself/participant with other NKB Practitioners/Clinicians at Peer Supervision, Meetings & Clinical Discussions.

Guardian/Representative Full Name (if applicable):

Guardian/Representative Signature (if applicable):

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Client Signature:

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Today's Date: *