Home $ Services $ Supported Independent Living $ External SIL Service RequestExternal SIL Service Request Step 1 of 250%Contact person/referrer* First Last Phone number/Email*Date of Referral MM slash DD slash YYYY Plan managed/Self-managed/NDIAParticipants full nameAddress* Street Address State Post Code Participants phone numberMobileParticipants email Date of Birth MM slash DD slash YYYY Gender Male FemaleNDIS NumberPlan start date MM slash DD slash YYYY Plan end Date MM slash DD slash YYYY Type of Supported Accommodation required 24/7 SIL SDA Shared Drop InCurrent Living Arrangements Living in another SIL Living with Parents Living Independently with drop in support Do you currently have SIL funding? Yes NoIf no, do you have a goal of finding suitable accommodation?When do you see yourself moving? 3 Months 6 Months 9 Months 12 Months Do you also need Capacity Building supports? Increasing independent living skills Work/placement Literacy/numeracy Computer skills Are you currently using another service Provider?Who is it? What services do you receive?Identified risk● Equipment required ● Environment ● Task ● Correct procedure ● Training requirement ● BehaviorsInformation about the Participants● Favorite activity ● Likes/Dislikes ● Do you have a BSP or other support documents to shareHow did you hear about CHSS? Advertising Promotional Event Word-of-mouth through a friend or family OtherIs there anything else you would like to share with us about you and your Independent Living goals?
