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aether
2026-01-07T02:18:49+00:00
Capacity Enquiry Form
General Overview
Information about the Participant.
Participant Initials
(Required)
Enter your name Initials
Email
(Required)
Phone
Age
(Required)
Gender
(Required)
Select your Gender
Male
Female
They/Them
Other
Participant Diagnosis
Please describe your diagnosis
Living Arrangements
(Required)
Who do they live with and where do they live (Suburb, general area, etc.)
Cultural Background & Language Preferences
Sexual Orientation
If relevant to Participant.
Religion
If relevant to Participant.
Allergies
If relevant to Participant.
Medical Conditions
For example: Asthma, Anxiety, Heart Disease (only list if relevant to Participant).
Communication Style or Needs
(Required)
For example: verbal, non-verbal, uses AAC, signs
Behavioural Considerations or Risk Factors
(Required)
Please list any triggers, safety concerns, restrictive practices in place or other.
Medication Management
If yes, what are they called?
Support Needs Overview
Information about the type of care we will need to provide for the Participant.
Specific Goals
(Required)
Does not necessarily NDIS, any goals the participant may have.
Functional Capacity
(Required)
For example: mobility, personal care, prompting.
Medical / Health Support Needs
(Required)
For example: epilepsy, PEG feeding, diabetes management.
Personal Care Required
(Required)
For example: toileting, dressing, showering – please specify the level of support required.
Manual Handling Involved
(Required)
For example: hoist transfers, assistance with walking.
Behaviour Support Needs
(Required)
For example: if a BSP is in place, level of worker experience needed.
Shift Requirements
To ensure appropriate support, the following requirements apply to the Support Worker assisting this participant.
Preferred or required days and times, shift length and frequency.
(Required)
Please include school holidays if applicable & whether overnight, weekend, or public holiday work is involved.
Whether regular, casual, or fill-in workers are required.
(Required)
Yes
No
Is this a Home and Living participant?
If yes, are they ILO, SIL, SDA? Please list if applicable.
What duties might the Support Worker be doing whilst on shift?
(Required)
Please list all the tasks the Support Worker may be required to do whilst supporting the Participant. For example: Take and attend appointments, assist with shopping, community access, support in the home, etc.
Transport
What is the general travel range?
(Required)
0-15KM
15-30KM
30-50KM
50KM +
What will most likely occur every shift, or every second or third shift.
Can Transport be claimed from the plan?
(Required)
Yes
No
Does The Support Worker need to drive the Participant?
(Required)
Yes
No
Can the Support Worker drive their own vehicle?
(Required)
Yes
No
Other
Other
Support Worker Preferences
What does a suitable Support Worker for this participant look like?
Gender
(Required)
For example: Male, Female, They/Them, Does not matter, etc.
Age
(Required)
For example: young and active, older and experienced.
Language & Cultural Background
Experience & Training
(Required)
What training or experience would the Support Worker ideally have or be required to have? (e.g., experience with autism, trauma-informed care, mental health, physical disability)
Interests & Hobbies
(Required)
To support compatibility, what hobbies or interests does the participant enjoy and might like to share with the Support Worker? (e.g., gardening, art, gaming, pets)
Documentation Applicable to Support - Are any of these in place?
Please note that we do not require them for the referral but knowing about them will assist in confirmation of capacity.
PBSP
Yes
No
Meal Time Management Plan
Yes
No
EPOA Documentation
Yes
No
Diabetes Management Plan
Yes
No
OTHER
Please specify if there is any other documentation available.
Other Considerations
Other considerations around the appropriate Support.
Does the participant have pets?
(Required)
Yes
No
Does someone smoke in the household?
(Required)
Yes
No
This includes vaping, cigarettes and any smoke residue in the house that the Support Workers can be exposed to.
Is the Support Worker required to be vaccinated?
(Required)
Yes
No
Worker needs to swim, lift, or assist with mobility?
(Required)
Yes
No
Does the Support Worker need to work independently or as part of a team? Will they be working alongside any other service providers?
(Required)
Did we miss something?
Please include any other relevant or important information that hasn’t been covered.
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