ࡱ > y pe bjbj e { { . 8 6 T nd & + (+ (+ (+ F- :: A t c c c c c c c $ f h /c D $- $- " D D /c (+ (+ (d bZ bZ bZ D F (+ (+ c bZ D c bZ bZ \ E] (+ D v ] b >d 0 nd ] , i NE r i E] i E] D D bZ D D D D D /c /c O D D D nd D D D D i D D D D D D D D D : A p p l i c a t i o n f o r S e r v i c e S e r v i c e R e q u i r e d : D a t e F o r m R e q u e s t e d : F O R M T E X T D a y F O R M C H E C K B O X R e s i d e n t i a l F O R M C H E C K B O X O u t r e a c h ( A d u l t ) F O R M C H E C K B O X O u t r e a c h ( C h i l d r e n ) F O R M C H E C K B O X S u p p o r t e d L i v i n g F O R M C H E C K B O X O t h e r F O R M C H E C K B O X p l e a s e s p e c i f y : F O R M T E X T S e c t i o n A - A p p l i c a n t D e t a i l s : N a m e : F O R M T E X T D a t e o f B i r t h : F O R M T E X T A d d r e s s : F O R M T E X T G e n d e r : F O R M T E X T R e l i g i o n : F O R M T E X T T e l e p h o n e N o . : F O R M T E X T M o b i l e N o . : F O R M T E X T E m a i l : F O R M T E X T S e c t i o n B - P a r e n t / G u a r d i a n / C a r e r D e t a i l s : F a t h e r / G u a r d i a n / C a r e r N a m e : F O R M T E X T M o t h e r s N a m e : F O R M T E X T A d d r e s s : F O R M T E X T A d d r e s s : ( i f d i f f e r e n t f r o m o p p o s i t e ) F O R M T E X T T e l e p h o n e N o . : F O R M T E X T M o b i l e N o . : F O R M T E X T E m a i l : F O R M T E X T T e l e p h o n e N o . : F O R M T E X T M o b i l e N o . : F O R M T E X T E m a i l : F O R M T E X T S i b l i n g s : ( P l e a s e l i s t ) G e n d e r : D a t e o f B i r t h : F O R M T E X T F O R M T E X T F O R M T E X T F O R M T E X T F O R M T E X T F O R M T E X T F O R M T E X T F O R M T E X T F O R M T E X T F O R M T E X T F O R M T E X T F O R M T E X T S e c t i o n C - C o n d i t i o n D e t a i l s : D i a g n o s i s : F O R M T E X T D i a g n o s e d b y : F O R M T E X T N a t u r e o f D i s a b i l i t y : F O R M T E X T A g e a t o n s e t o f c o n d i t i o n : F O R M T E X T A n y o t h e r k n o w n d i s a b i l i t y ( p l e a s e s p e c i f y ) ? F O R M T E X T D o e s a p p l i c a n t s u f f e r f r o m e p i l e p s y ? Y e s F O R M C H E C K B O X N o F O R M C H E C KBOX Is there any evidence of hearing or visual impairment? Yes FORMCHECKBOX No FORMCHECKBOX Section D - Personal Health: Is the applicant on any medication? (give details): Yes FORMCHECKBOX No FORMCHECKBOX FORMTEXT H a s t h e a p p l i c a n t h a d a n y s e r i o u s i l l n e s s ? ( p l e a s e d e s c r i b e ) : Y e s F O R M C H E C K B O X N o F O R M C H E C K B O X F O R M T E X T D e t a i l s o f a n y k n o w n a l l e r g i e s : F O R M T E X T S e c t i o n E - P l a c e m e n t s : P r e s e n t P l a c e m e n t o r S e r v i c e ( S c h o o l , C e n t r e , E m p l o y m e n t ) : F O R M T E X T P l e a s e g i v e r e a s o n s f o r w a n t i n g a n o t h e r f a c i l i t y : F O R M T E X T P r e v i o u s P l a c e m e n t s : P l a c e m e n t s / S c h o o l s D a t e o f E n t r y D a t e o f L e a v i n g F O R M T E X T F O R M T E X T F O R M T E X T F O R M T E X T F O R M T E X T F O R M T E X T F O R M T E X T F O R M T E X T F O R M T E X T F O R M T E X T F O R M T E X T F O R M T E X T F O R M T E X T F O R M T E X T F O R M T E X T F O R M T E X T F O R M T E X T F O R M T E X T S e c t i o n F - C o m m u n i c a t i o n : A p p l i c a n t s f i r s t l a n g u a g e ? : F O R M T E X T D o e s t h e a p p l i c a n t u s e s p o k e n l a n g u a g e ? ( p l e a s e d e s c r i b e ) : Y e s F O R M C H E C K B O X N o F O R M C H E C K B O X F O R M T E X T U s e o f g e s t u r e / m i m e ( p l e a s e d e s c r i b e ) : F O R M T E X T A r t i c u l a t i o n , e . g . e c h o l a l i c , s t i l t e d s p e e c h , e t c ( p l e a s e d e s c r i b e ) F O R M T E X T H o w m u c h c a n t h e a p p l i c a n t u n d e r s t a n d w h a t i s s a i d t o t h e m ? ( p l e a s e d e s c r i b e ) : F O R M T E X T S e c t i o n G - R e l a t i o n s h i p s ( p l e a s e d e s c r i b e ) : W i t h F a m i l y : F O R M T E X T W i t h O t h e r y o u n g p e o p l e : F O R M T E X T W i t h A d u l t s : F O R M T E X T H a s t h e a p p l i c a n t l i v e d a w a y f r o m h o m e b e f o r e ( g i v e d e t a i l s ) : Y e s F O R M C H E C K B O X N o F O R M C H E C K B O X F O R M T E X T S e c t i o n H - M o t o r C o - o r d i n a t i o n ( p l e a s e d e s c r i b e ) : F O R M T E X T S e c t i o n I - S e l f C a r e : C a n a p p l i c a n t ( p l e a s e x a l l t h a t a p p l y ) : I n d e p e n d e n t l y x V e r b a l P r ompt xPhysical Assistance xUse knife and fork FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Bathe him / herself FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Clean teeth FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Comb hair FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Wash hair FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Manicure / pedicure FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Get up without being called FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Change clothes appropriately FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Shave (wet / electric) FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Dress him / herself FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Know when to change clothes FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Personal hygiene FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Clean shoes FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Prepare drinks / snacks FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Section J - Social Adequacy: Any difficulties with: Using toilet adequately: Day - Yes FORMCHECKBOX No FORMCHECKBOX Night - Yes FORMCHECKBOX No FORMCHECKBOX Eating (please describe): FORMTEXT S l e e p i n g ( p l e a s e d e s c r i b e ) : F O R M T E X T O b s e s s i o n s a n d r i t u a l i s m ( p l e a s e d e s c r i b e ) : F O R M T E X T I s t h e a p p l i c a n t o v e r a c t i v e ? Y e s F O R M C H E C K B O X N o F O R M C H E C K B O X S e c t i o n K - B e h a v i o u r P r o b l e m s ( p l e a s e s p e c i f y ) : Y e s x N o x A d d i t i o n a l C o m m e n t s T e m p e r c o n t r o l F O R M C H E C K B O X F O R M C H E C K B O X F O R M T E X T A g g r e s s i o n F O R M C H E C K B O X F O R M C H E C K B O X F O R M T E X T S e l f I n j u r y ( b i t i n g , h i t t i n g , h e a d b a n g i n g ) F O R M C H E C K B O X F O R M C H E C K B O X F O R M T E X T D e s t r u c t i v e n e s s ( b r e a k i n g , c h e w i n g ) F O R M C H E C K B O X F O R M C H E C K B O X F O R M T E X T S c r e a m i n g / r o a r i n g F O R M C H E C K B O X F O R M C H E C K B O X F O R M T E X T R u n n i n g a w a y F O R M C H E C K B O X F O R M C H E C K B O X F O R M T E X T T e a r i n g F O R M C H E C K B O X F O R M C H E C K B O X F O R M T E X T A n y o t h e r i n f o r m a t i o n : F O R M T E X T S e c t i o n L - E d u c a t i o n a l A t t a i n m e n t s : C a n a p p l i c a n t : Y e s x N o x A d d i t i o n a l C o m m e n t s R e a d ( p l e a s e s p e c i f y ) F O R M C H E C K B O X F O R M C H E C K B O X F O R M T E X T I f n o t , c a n t h e y r e c o g n i s e d s i g n s s u c h a s K e e p O u t , D o N o t T o u c h , L a d i e s / G e n t l e m e n ? F O R M C H E C K B O X F O R M C H E C K B O X F O R M T E X T W r i t e ( n a m e / l e t t e r s ) F O R M C H E C K B O X F O R M C H E C K B O X F O R M T E X T T e l l t i m e F O R M C H E C K B O X F O R M C H E C K B O X F O R M T E X T R e c o g n i s e m o n e y F O R M C H E C K B O X F O R M C H E C K B O X F O R M T E X T D o t h e y h a v e a n y i d e a o f p u r c h a s i n g p o w e r o f m o n e y ? 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