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Capabilities assessment
Capabilities assessment
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Name
*
First
Middle
Last
Date of birth
Gender
Male
Female
Other
Prefer not to disclose
Mobile
*
Email
*
Address
*
City
*
Post code
*
State / Province / Region
*
State / Province / Region
NSW
VIC
ACT
NT
QLD
TAS
WA
SA
Country
*
Australia
Participant NDIS number
NDIS plan type
Plan managed
Agency managed
Self managed
File upload (e.g NDIS plan, assessments, medical reports)
Click or drag a file to this area to upload.
Services of interest
Capacity building and skill development
Community participation and/or Social connection program
Intergenerational program
What is your main disability?
Physical disability
Intellectual disability
Sensory disability (e.g blindness, deafness)
Developmental disability (e.g autism)
Mental health condition
Other
Please specify
How does your disability or condition affect your mobility?
No aids or mobility used. Able to walk independently and without assistance
Requires low level aids e.g., walking stick/frame
Mobility low/slow with the use of aids
Requires assistance with getting in/out of vehicles
No mobility, requires hoisting into/out of mobility aid. Limited movement in upper limbs
How would you rate your communication capabilities?
Clear communication, no aids or speech impediments
Slight impediments and may require clarification
earing loss/sight impaired/speech garbled
Completely non-verbal – requires intimate knowledge and understanding of communication patterns
Are there any specific concerns regarding your cognitive condition?
No
Yes - Requires simplified directives, can work independently and is able to work through issues
Yes - Understands end goal, requires assistance with understanding steps in between
Yes - Requires guidance and assistance with each step. Needs time to process each stage
Yes - Full support required
Are there any safety alerts that we should be aware of?
No
Yes
Please specify safety alerts
What is your current level of independent living skills? (select one)
Fully independent: Manage all daily activities without assistance
Partially independent: Need occasional help with certain tasks
Supported: Require regular assistance for most daily activities
Fully supported: Depend on full-time assistance for daily living
Please list the specific skills you would like to learn or improve upon
What are your interests or hobbies?
Do you have any preference or concerns regarding interacting with older adults?
Yes
No
Additional comments
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