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Samuel Brus
samuel@gmail.com
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Client Management
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Title
*
First Name
*
Middel Name
*
Last Name
*
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Additional Name
*
Name Type
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Birth Sex
*
Male
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DOB
Age
Estimated Date of Birth
*
Yes
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Deceased Date
Client Alerts
Client Alert Details
Client Alert Details
Critical Medical Information
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Type
Level
Requires Plan
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Clinical Diagnosis/ Disability/ Mental Health
*
Allergies and Adverse Reactions
*
Yes
No
Allergies and Adverse Reactions Notes
Asthma
*
Yes
No
Asthma Notes
Diabetes
*
Yes
No
Diabetes Notes
EPI Pen
*
Yes
No
EPI Notes
Medications Taken
*
Yes
No
Medications Taken Notes
Seizures
*
Yes
No
Seizures Notes
Other
*
Yes
No
Other Notes
* Please see contacts section for medical contacts.
DOB
Age
Estimated Date of Birth
*
Yes
No
Deceased Date
About Me
Height (CM)
Weight (KG)
Eye Colour
Hair Colour
Skin Colour
Identifying Features
My Contact Details
Address
Mailing Address is the same as Address
Mailing Address
Contact Number
Email
Mobile Number
Fax Number
Culture, Language, Religion
Culturally and Linguistically Diverse (CALD) Background
Yes
No
Country of Birth
Australia
Other (Specify)
Country of Birth Notes
Mailing Address is the same as Address
Mailing Address
Ethnicity
Languages
Dialect
Interpreter Required
Yes
No
Interpreter Required Notes
Indigenous Status
Not Stated
Aboriginal but not Torres Strait Islander
Torres Strait Islander but not Aboriginal
Both Aboriginal and Torres Strait Islander
Neither Aboriginal nor Torres Strait Islander
Indigenous Country/Nation
Indigenous Language
Religion
Religious and Cultural Practices
yes
No
Religious and Cultural Practices Notes
Education
Add Education
School / Institution
Type
Start Date
End Date
Actions
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Legal Orders and Authorities
Add Legal Order
Legal Order Type
Order Summary
Start Date
End Date
Actions
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Notes
Card, Concessions & IDs
Client Id
External Id
NDIS Client Id
CoS Id
Centrelink CRN
Companion Card NumberN
Companion Card Expiry Date
DSS Case Id Number
DSS Client Id Number
DVA Card Type
GOld
Orange
White
DVA Card Number
DVA Card Expiry Date
Healthcare Card Number
Healthcare Card Expiry Date
Healthcare Card Number
Healthcare Card Expiry Date
Individual Healthcare Identifier - IHI
Child Story Identifier from CS
Library Card Number
Library Card Expiry Date
Medicare Card Number
Medicare Card Expiry Date
Pension Number
Pension Number Expiry Date
Private Health Insurance Provider
Private Health Insurance Card Number
Private Health Insurance Card Expiry Date
Proof Of Age Card Number
Proof Of Age Card Expiry Date
Public Guardian Client Number
Public Trust Client Number
Seniors Card Number
Seniors Card Expiry Date
Tax File Number
Assets and Possessions
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Asset Description
Asset Location
Replacement Value
Receipt Available
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External Client Links
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Label
Description
Hyperlink
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Contacts
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Name
Contact Type
Relationship
Status
Contact info
Actions
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Assigned Staff
Selected Staff
Alabama
Alaska
California
Delaware
Tennessee
Texas
Washington
Selected Key Workers
Hierarchy
Add Hierarchy
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State
Region
Unit
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Living Arrangements / Placement History
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Name
Type
Organisation
Commencement Date
Exit Date
Actions
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Programs
Client Program
Select Client Program
Disability
OOHC Residential
Foster Care
Programs
Community Access / Participation
Day Program
Disability
Home Care
Kinship Care
Out of Home Care - Foster
Out of Home Care - Residential
Residential - Family or Relative
Residential - Group Home
Respite Care
Other (Specify)
Notes
Bathing and Grooming
Assistance - Clean Teeth
Yes
No
Assistance - Clean Teeth Notes
Assistance - Fill a bath or run a shower
Yes
No
Assistance - Fill a bath or run a shower Notes
Assistance - Shaving
Yes
No
Assistance - Shaving Notes
Assistance - Washing Hair
Yes
No
Assistance - Washing Hair Notes
Assistance - Washing Hands
Yes
No
Assistance - Washing Hands Notes
Bath or Shower Preference
Bath
Shower
Sponge Bath
Dress by themself
Yes
No
Dress by themself Notes
Hot Water Awareness (Assess Risk)
Yes
No
Hot Water Awareness (Assess Risk) Notes
Manage Buttons, Zippers etc. by self
Yes
No
Manage Buttons, Zippers etc. by self Notes
Normal Bathing Time
Special Bath Oil, Shampoo, Soap
Yes
No
Special Bath Oil, Shampoo, Soap Notes
Supervision Required Whilst Bathing
Yes
No
Supervision Required Whilst Bathing Notes
YesNo * If the client has Seizures then a Seizure Plan needs to be in place. Please attach plan. Plan stored in Documents under Medical.
Bedtime Routine
Continence Aids to Bed
Yes
No
Continence Aids to Bed Notes
Indicates when wants to go to bed
Yes
No
Indicates when wants to go to bed Notes
Problems sleeping away from normal residence
Yes
No
Problems sleeping away from normal residence Notes
Sleeps with Bedroom Door Closed
Yes
No
Sleeps with Bedroom Door Closed Notes
Sleeps with Light On
Yes
No
Sleeps with Light On Notes
Sleeps in a Single Room
Yes
No
Sleeps in a Single Room Notes
Special Sleeping Needs (e.g. two pillows etc.)
Yes
No
Special Sleeping Needs (e.g. two pillows etc.) Notes
Re-positioned during night
Yes
No
Re-positioned during night Notes
Sleep through the night
Yes
No
Sleep through the night Notes
Usual Bedtime Routine
Yes
No
Usual Bedtime Routine Notes
Other (Specify)
Yes
No
Other (Specify) Notes
Behaviour Support
Absconding / Wandering(Assess Risk)
Yes
No
Absconding / Wandering(Assess Risk) Notes
Abusive Language / Swearing(Assess Risk)
Yes
No
Abusive Language / Swearing(Assess Risk) Notes
Aggression(Assess Risk)
Yes
No
Aggression(Assess Risk) Notes
Crying / Screaming / Other Noisy Behaviours(Assess Risk)
Yes
No
Crying / Screaming / Other Noisy Behaviours(Assess Risk) Notes
Eating Non Edible Substance
Yes
No
Eating Non Edible Substance Notes
Non Compliance(Assess Risk)
Yes
No
Non Compliance(Assess Risk) Notes
Property Damage(Assess Risk)
Yes
No
Property Damage(Assess Risk) Notes
Obsessive / Repetitive(Assess Risk)
Yes
No
Obsessive / Repetitive(Assess Risk) Notes
Self-Injuries(Assess Risk)
Yes
No
Self-Injuries(Assess Risk) Notes
Self Stimulatory Behaviour(thumb sucking, rocking etc.) (Assess Risk)
Yes
No
Other Behaviours(Assess Risk)
Yes
No
Other Behaviours(Assess Risk) Notes
How are these Behaviours Managed?
Behaviour Support Plan
Yes
No
Behaviour Support Plan Notes
Behaviour Support Plan Approved Date
Behaviour Support Plan Review Date 1
Behaviour Support Plan Review Date 2
Behaviour Support Plan Review Date 3
Behaviour plan
Please attach the Behaviour Management Plan.
Stored in Documents.
Communication
Please describe how the client communicates.
Anger
Communicaton Method
Compic
Computer
Facial Expression
Gestures
Non Verbal
Pictures
Signs
Speech
Vocalisation
Other
Notes
Communications Plan Available
Yes
No
Happiness
Hunger
Pain - how is this indicated
Reading
Sadness
Staying Away from Home (previous reactions ie. in other Respite or Temporary Care)
Telephone Usage
Thirst
Toileting
Writing
Community Access
Likes
Dislikes
Additional Resources or Supports Required
Yes
No
Attend School / Vocation
Yes
No
Fears or Phobias (e.g. Escalator/ Lifts etc.)
Yes
No
No Participation due to Medical Reasons
Yes
No
Public Transport with Support Staff
Yes
No
Preferred Seating Requirements
Yes
No
Recommended Maximum Travel Time
Yes
No
Require Activities whilst Travelling ( e.g. Books, Music etc.)
Yes
No
Road Safety - is the Client Aware?
Yes
No
Small Groups with Support Staff
Yes
No
Travel Sickness
Yes
No
Remains Seated Whilst Travelling
Yes
No
Removes Seatbelt Whilst Travelling
Yes
No
Swimming/Water Sports Incontinence
Yes
No
Swimming/Water Sports Independnt/Support Required
Yes
No
Swimming/Water Sports Participation
Yes
No
Swimming/Water Sports Specialised Equipment
Yes
No
Swimming/Water Sports Wheelchair Access
Yes
No
Eating, Drinking & Mealtimes
Breakfast (Usual Time)
Morning Tea (Usual Time)
Lunch (Usual Time)
Afternoon Tea (Usual Time)
Dinner (Usual Time)
Supper (Usual Time)
Dislikes - Food and Drink
Yes
No
Likes - Food and Drink
Yes
No
Assistance with Eating or Drinking
Yes
No
Cultural or Religious Food Practices
Yes
No
Encouragement to Eat
Yes
No
Food Allergies / Adverse Reactions
Yes
No
Left or Right Handed
Left
Right
Meals Served
Chopped
Mashed
Normal
Pureed
Other
Meals Served Notes
Nutrition Plan
Yes
No
Special Aids for Eating or Drinking
Yes
No
Special Diet Requirements
Yes
No
Tube Feeding Required (Management Plan required)
Yes
No
Utensils Used
Bowl
Cut out cup
Fingers
Fork
Plastic Spoon Only
Plate
Spoon
Straw / Cup
Other (Specify)
Notes
Menstruation
Assistance Required
Yes
No
Duration of Menses (day)
Duration of Menses (day)
Mobility and Movement
Difficulty moving on Uneven or Rough Ground (Assess Risk)
Yes
No
Hearing or Vision Impaired (Assess Risk)
Yes
No
Mobility Level (Assess Risk)
Fully Mobile
Needs Assistance to Walk
Uses Other Aids
Uses Wheelchair for Mobility
Slight Physical Disability
Other Mobility or Movement Issues (Assess Risk)
Yes
No
Special Aids Required (e.g. Glasses, Helmets, Orthodontics, Other Splints, Walking Frame, Wheelchair etc.) (Assess Risk)
Yes
No
Travelling in a Vehicle (special seating required) (Assess Risk)
Yes
No
Sun Safety
Sun Safety
Yes
No
Swimming & Water Sports
Independently Swim
Yes
No
Participate in Swimming or Water Sports
Yes
No
Support whilst in Water - Required
One on One
Two on one
Wheelchair Access Required
Yes
No
Toileting
Assistance Required - Toilet Paper
Yes
No
Assistance Required - Washing Hands
Yes
No
Assistance - Special Aids or Equipment(Manual Handling Plan)
One on One
Two on one
Aware of needing to use toilet(Please Explain)
Yes
No
Constipation - Any Signs, Symptoms or Behaviour changes
Yes
No
Constipation Issues
Yes
No
Constipation - Prescribed by Doctor
Yes
No
Distinguish Public Toilet - Male/Female Signs
Yes
No
Fully Independent Toileting
Yes
No
Inappropriate Behaviours Relating to Toileting(How Managed?)
Yes
No
Incontinent
Yes
No
Preferred Ways of Toileting(e.g Males sitting to Urinate, using a Commode)
Yes
No
Routine - Day Time
Routine - Nighttime
Toilet Timed
Yes
No
Use Continent Aids
Yes
No
Agreements / Consents / Permissions
Dislikes
Assessments
Yes
No
Automatically Approve Billing
Yes
No
Automatically Approve Billing Notes
Authorisation for Collection
Yes
No
Community Access
Yes
No
Communications Book Reading
Yes
No
Date of Consent
Emergency Assistance
Yes
No
Emergency Medical Treatment
Yes
No
Exchange of Information
Yes
No
Letter Opening
Yes
No
Medications - Administer
Yes
No
Name (Giving Consent)
Outings Organised by the Service
Yes
No
Photograph
Yes
No
Service Agreement
Yes
No
Service Agreement From Date
Service Agreement To Date
Service Costs
Yes
No
Travel in Vehicle
Yes
No
Assessments
Dislikes
Assessment - CAT Score [?]
Level 1 (Low) - General Foster Care (GFC)
Level 2 (Low) - General Foster Care+1 (GFC+1)
Level 3 (Medium) - General Foster Care+2 (GFC+2)
Level 4 (Medium) - Intensive Foster Care (IFC)
Level 5 (High) - Residential Care (RC)
Level 6 (High) - Intensive Residential Care (IRC)
Assessment - CAT Score Date Last Completed
Assessment - Level of Support
Low
Medium
high
Assessment - Level of Support Date Last Completed
Notes
Case Plan
Case Plan
Yes
No
Current Case Management Responsibility
Community Services
Non-government agency
Agency Providing Case Management Services
Goal of Case Plan (Placement)
Select Goal of Case Plan (Placement)
Adoption
Case Plan Goal Not Recorded
Commonwealth long term placement with an Authorised Carer
Independent Living
Order for sole parental responsibility under Sect 149
Placement under Parenting order under Family Law Act 1975
Placement with member(s) of same kinship group
Other (Specify)
Goal of Case Plan (Placement) Other
Included Case Plan Elements
Behaviour Support Plan
Contact Plan
Cultural Support Plan
Education Plan
Leaving Care Plan
Therapeutic Plan
Transition Plan
Future Plan
Health Management Plan
Other (Specify)
Other
Behaviour Support Plan Id
Case Plan Date Created
Case Plan Review By Date
Case Plan Review Last Conducted Date
Notes
My Goals
In Progress
On Hold
Achieved
Not Achieved
All
Goal
Start Date
Planned Achievement Date
Review Date
Planned Achievement Date
Progress Summary
Actions
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Goal
Start Date
Planned Achievement Date
Review Date
Planned Achievement Date
Progress Summary
Actions
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Goal
Start Date
Achieved On
Progress Summary
Actions
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Goal
Start Date
Planned Achievement Date
Review Date
Last Progress Update
Progress Summary
Actions
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Goal
Status
Start Date
Last Progress Update
Progress Summary
Actions
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Risk Management / Assessments
Risk Assessment Completed
Yes
No
Rating/Comments
Risk Assessment Completed Date
Action Plan Date
Practice
Add Restricted Practice
Export to pdf
Practice
Type
Status
Start Date
Expiry Date
Review Date
Actions
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Benchmark
Bedtime Benchmark Goal
Bedtime Goal Achieved
Bedtime Entry
Diet Plan Am Benchmark Goal
Diet Plan AM Goal Achieved
Diet Plan Entry Am
Diet Plan Pm Benchmark Goal
Diet Plan Pm Goal Achieved
Diet Plan Entry Pm
Diet Plan Night Benchmark Goal
Diet Plan Night Goal Achieved
Diet Plan Entry Night
Education Vocation Benchmark Goal
Education Vocation Goal Achieved
Education Vocation Entry
Centre Based Program Benchmark Goal
Centre Based Program Goal Achieved
Centre Based Program Entry
Community Participation Benchmark Goal
Community Participation Goal Achieved
Community Participation Entry
Employment Benchmark Goal
Employment Goal Achieved
Employment Entry
Vocational Benchmark Goal
Vocational Goal Achieved
Vocational Entry
Volunteering Benchmark Goal
Volunteering Goal Achieved
Volunteering Entry
Exercise Am Benchmark Goal
Exercise Am Goal Achieved
Exercise Entry Am
Exercise Pm Benchmark Goal
Exercise Pm Goal Achieved
Exercise Entry Pm
Exercise Night Benchmark Goal
Exercise Night Goal Achieved
Exercise Entry Night
Family Contact Benchmark Goal
Family Contact Goal Achieved
Family Contact Entry
Family Contact Phone Benchmark Goal
Family Contact Phone Goal Achieved
Family Contact Phone Entry
Family Contact Face to Face Benchmark Goal
Family Contact Face to Face Goal Achieved
Family Contact Face to Face Entry
General Illness Benchmark Goal
General Illness Goal Achieved
General Illness Entry
Incident Benchmark Goal
Incident Entry
Legal / Government Appointment Benchmark Goal
Legal / Government Appointment Goal Achieved
Legal / Government Appointment Entry
Medical Appointments Benchmark Goal
Medical Appointments Goal Achieved
Medical Appointments Entry
Medical Reviews Benchmark Goal
Medical Reviews Goal Achieved
Medical Reviews Entry
Respite Goal
Respite Goal Achieved
Respite Entry
Menstruation Benchmark Goal
Menstruation Goal Achieved
Menstruation Entry
Personal Care Am Benchmark Goal
Personal Care Am Goal Achieved
Personal Care Entry Am
Personal Care Pm Benchmark Goal
Personal Care Pm Goal Achieved
Personal Care Entry Pm
Personal Care Night Benchmark Goal
Personal Care Night Goal Achieved
Personal Care Entry Night
Reference Person Meetings Benchmark Goal
Reference Person Meetings Goal Achieved
Reference Person Meetings Entry
Living Skills Benchmark Goal
Living Skills Goal Achieved
Living Skills Entry
Social Skills Benchmark Goal
Social Skills Goal Achieved
Social Skills Entry
Culture Engagement Benchmark Goal
Culture Engagement Goal Achieved
Culture Engagement Entry
Identity Development Benchmark Goal
Identity Development Goal Achieved
Identity Development Entry
Leaving / Transitioning Care Benchmark Goal
Leaving / Transitioning Care Goal Achieved
Leaving / Transitioning Care Entry
Leisure, Sport, Recreation Benchmark Goal
Leisure, Sport, Recreation Goal Achieved
Leisure, Sport, Recreation Entry
Therapy Sessions Benchmark Goal
Therapy Sessions Goal Achieved
Therapy Sessions Entry
Wake Benchmark Goal
Wake Goal Achieved
Wake Entry
Weight Benchmark Goal
Weight Goal Achieved
Weight Entry
Diagnosed Disability
×
Diagnosis Type [?] *
Aboriginal Tribal Name
Alias
Also Known As
Birth Name
Cultural Name
Legal Name
Pre-adoptive Name
Preferred Name
Previous/Maiden Name
Professional Name
Level [?] *
Aboriginal Tribal Name
Alias
Also Known As
Birth Name
Cultural Name
Legal Name
Pre-adoptive Name
Preferred Name
Previous/Maiden Name
Professional Name
Diagnosis
*
Diagnosed by a qualified professional as having any disabilities
Yes
No
Requires Management Plan
Yes
No
Notes
Add Education
×
School / Institution
*
Type
Pre-school/ Day Care
Primary
Secondary
Special School / Program
TAFE
University
None
Other (Specify)
Description
*
Start Date
*
End Date
*
Legal Orders and Authorities
×
Order Type
*
Temporary Care Agreement
Interim Care Order
Final Care Order
Parental Responsibility Order
Guardianship Order
Adoption Order
Other (Specify)
Order Type Other
*
Order Summary
*
Order Details
*
Start Date
*
End Date
*
Amendments to Order
*
Amendment Date
*
Notes
*
Assets and Possessions
×
Asset Description
*
Asset Location
*
Replacement Value
*
Receipt Available
Yes
No
External Client Link Details
×
Label
*
Description
Hyperlink
*
Contact Details
×
Title
Contact Name / Organisation
*
Contact Type
Advocate
Carer (Kinship)
Carer (Primary)
Carer (Respite)
Carer (Secondary)
Case Manager
Case Worker
Community Group
Counsellor
Dentist
Dietitian
Education
Family
General Practitioner
Contact Type Other
Relationship to Client
Aunt
Brother
Boarder
Cousin
Daughter
Father
Guardian
Half Brother
Half Sister
Husband
Maternal Grandfather
Maternal Grandmother
Mother
Nephew
Relationship to Client Other
Relationship Status
Select Relationship Status
Normal
Deceased
Severed
Tenuous
Emergency Contact
Select Emergency Contact
Primary
Secondary
Next Person to be Notified
Home Number
Mobile Number
Work Number
Fax Number
Email
Address
Indigenous Status
Select Indigenous Status
Not Stated
Aboriginal but not Torres Strait Islander
Torres Strait Islander but not Aboriginal
Both Aboriginal and Torres Strait Islander
Neither Aboriginal nor Torres Strait Islander
Indigenous Nation/Country
Additional Cultural Requirements/Details
Next of Kin
Guardian
Effective Date From
Effective Date To
Next of Kin
Guardian
Orders - Apprehended Violence Order
Yes
No
Orders - Parenting
Yes
No
Assistance Filling out Forms
Yes
No
Language Spoken
Yes
No
Interpreter Required
Yes
No
Power of Attorney
Yes
No
Add Hierarchy
×
State
Please Select State
WA
Region
Please Select Region
undefined
Please Select a Unit
*
Living Arrangements / Placement History
×
Type
Drop in Support
Family Group Home
Foster Care
Lives Alone
Lives with Family
Lives with Others
Therapeutic Residential Care
Refugee Care
Kinship/Relative Care
Residential Care - Group Home
Residential Care - Other
Respite Care
Semi Independent
Other
Organisation
Name
*
Is there a Placement Agreement?
Yes
No
Primary Carer
Commencement Date
Reason for Entering Placement
Select Reason for Entering Placement
Change in NGO/Provider
Child Protection Reasons (Child at risk)
Due to Legal Order
Exit from Custody/Incarceration
Hospitalisation
Improved Status
Increased Needs
Parent/Carer illness (physical, psychological) or significant family breakdown
Parent/Carer need of periodical relief
Person moved into area
Previous Placement Breakdown
Transitioning to Independence
Other (Specify)
Change in Carer/Parent Circumstances
Entering into Voluntary Care
Yes
No
Is the Person Self-Placed?
Yes
No
Legal Status/Placement Status
Legal Status/Placement Status
Carer responsibilityof DG removal or assumption of care
Court Order
Court Order of Parental responsibility (*Full or Share) order
Detached refuge
Guardianship Order
No Order
Official Public Guardian
Parental responsibility for interstate ward
PR to Minister - Final Order
PR to Minister - Interim Order
PR to Minister - Shared Care
Pre-adoption
Relative/kinship care
Sole Parental Responsibility
Temporary care management
Temporary Care Order
Voluntary care
Other (Specify)
After Care
Purpose of Placement
Select Purpose of Placement
Emergency Care
Pending Court Decision
Permanent Care
Respite Care
Transition to Adoption
Transition to Independence
Transition to Permanent Care Transition to Restoration
Other (Specify)
Assessment (no court decision pending)
Services provided by Agency to Client prior to entering care
Adolescent Support
Advocacy
Day Services
Family
Family Support
Respite
Restoration
Therapeutic Support
None
Other
Siblings/Family in Same Placement
Select Purpose of Placement
Family or Relative placed in care together
No siblings
Placed with at least one sibling
Siblings in care
Unknown
All siblings in care are placed together
Placement is culturally compatible
Yes
No
Aboriginal and Torres Strait Islander Placement Principles applied
Yes
No
Exit Details
Is this Move Planned or Unplanned?
Yes
No
Reason for exiting the placement
Admitted to Other Institution Setting
Admitted to Residential Care Setting
Adoption
Allegation against carer
Change in Carer/Parent Circumstances
Change in NGO/Provider
Child protection reasons (Child at risk)
Due to Legal Order
Entry to Custody/Incarceration
Hospitalisation
Improved Status
Increased Needs
Independent living
Now Receiving Other Community Based Service
Order for sole parental responsibility under Sect 149 has been made
Parent/Carer illness (physical, psychological)
Parent/Carer need of periodical relief
Parenting order under Family law Act 1975 of Commonwealth has been made
Person Deceased
Person missing
Person No Longer Living in Area
Placement breakdown
Placement with member(s) of same kinship group
Restored to care of parent(s)
Significant family breakdown
Switched to Another Provider
Transitioning to Independent living
Other (Specify)
Placement Exit Notes
Exit Date
Is the person leaving the care period with your agency
Yes
No
Person referred to any other Services
Yes
No
Documentation completed to support move? (E.g. Transitioning Care Plan)
Yes
No
Restricted Practice
×
Practice
*
Restricted Practice Status
Active
Inactive
RPA Start Date
Restricted Practice Inactive Date
Type
Exclusionary Time Out
Psychotropic Medication (PRN)
Psychotropic Medication (Routine)
Physical Restraint
Response Cost
Restricted Access
Room Search
Seclusion
RPA Description
RPA Panel Date
RPA Panel Outcomes
Ceased
Full Authorisation
Interim
Lapsed
Not Authorised
Review Date
Expiry Date
Consenter
Appointed Guardian
CEO Authorisation
FACS
Family Member
Parent
Self
TBC
First Approved Date
