So, you’d like to apply for an Ability Apartment, please fill in this form and read page 18 for submission details.

We recommend that you immediately lodge a request with the NDIA for a ‘change of circumstances’ review so that you can apply for 70 hours of Support Coordination and 50 hours of Allied Health so that assessments can be conducted and reports lodged to the NDIA.

EXPRESSION OF INTEREST FORMABILITY APARTMENTS

WHICH ABILITY APARTMENTS LOCATION ARE YOU INTERESTED IN?

£ Gosford Central Central Coast NSW

£ Gosford Showground Road Central Coast NSW

£ Guildford Western Sydney

£ Townsville Far North QLD

£ Villawood Western Sydney

1. APPLICANT DETAILS – Let’s find out more about you

Name:

Current Address:

Current Address:

Phone Number:

Email:

Date of Birth:

Gender:

£ Male

£ Female

£ Other

1.1 What is your primary disability?

£ Acquired Brain Injury

£ Spinal Cord Injury

£ Cerebral Palsy

£ Progressive Neurological Condition (such as Multiple Sclerosis, Motor Neurone Disease, Huntington’s)

£ Other – Please provide details:

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1.2 Do you have a secondary disability or multiple disabilities? (including hearing or vision impairments)

1.3 Where do you currently live?

£ With family

£ With friends

£ Alone in your home (privately purchased)

£ Alone in home (rental)

£ Nursing home/residential aged care (RAC)

£ Group home shared supported accommodation

£ Boarding house/Supported Residential Services (SRS)

£ Hospital

£ Other – Please provide details:

1.4 What is your main source of income?

£ Disability/other pension

£ Income insurance/other compensation

£ Paid work

£ Private income

£ Other – Please provide details:

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2. DETAILS ABOUT PERSON COMPLETING THIS FORM

2.1 Who is filling out this form?

£ Me (applicant)

£ Family/friend

£ Organisation

£ Other – Please provide details:

2.2 If someone else is filling in this form for you

Their name:

Relationship to applicant:

Organisation (if applicable):

Contact phone number:

Email address:

3. COMMUNICATING WITH YOU

3.1 How would you like us to contact you (applicant) about your expression of interest? (All our contact with you will be based on what you say below.)

£ Contact me (applicant) via my specified details

£ Contact someone else (please specify)

Their name:

Relationship to you:

Preferred contact method:

Phone number:

Email address:

Postal address: Postal address:

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4. LIVING IN ABILITY APARTMENTS

4.1 If you were successful in being selected for an apartment, which living arrangements would you be comfortable with? (You can select multiple options.)

£ Alone

£ Sharing with one other (Male)

£ Sharing with one other (Female)

£ Sharing with one other (No gender preference)

£ Other – Please provide details:

4.2 What are the main reasons you are interested in applying to live in this housing? (ie I’d like to live independently)

4.3 What do you want to do more of by yourself? (These are called your independent living goals.)

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5. YOU AND THE NDIS

5.1 What is your current NDIS status?

£ NDIS participant with current plan

£ NDIS participant waiting for plan approval

£ NDIS participant waiting for planning meeting

£ Waiting for NDIS eligibility approval

£ Waiting for NDIS to come to my area

£ Not NDIS eligible

Your NDIS Number:

5.2 If you have a NDIS plan will you share a copy with us? (Please attach your plan to this EOI form.)

£ Yes

£ No

5.3 What housing supports are in your current plan?

£ Specialist Disability Accomodation (SDA) approval. If you have SDA approval, what ‘design category’ do you have?

£ High Physical Support

£ Robust

£ Fully Accessible

£ Improved livability

£ Basic

£ Not sure

£ Exploring Housing Options (no SDA approval yet but funding for Support Coordinator and Allied Health Assessments to help you find suitable housing)

£ Support Co-ordinator limits for hours (between 1–75 hours)

£ Allied Health Assessments limits hours (between 1–50 hours)

£ Goal to move out of where you are living and a plan review date set

£ None

£ None

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6. UNDERSTANDING MORE ABOUT YOU

6.1 How do you talk to and understand others? (You can tick more than one box.)

£ I can talk with and understand other people without help

£ I can talk with and understand other people with help because of speech difficulties or lack of confidence

£ I can talk with and understand other people with help to keep me on track, to remember what’s been said and to say the right things (cognitive-communication difficulties)

£ I am unable to talk, so I use a communication device Please write the details here about the help you need for this area:

6.2 How do you walk or get around?

£ I can walk without help

£ I can walk with some help from a person to keep me safe

£ I can walk with equipment (such as crutch, cane etc)

£ I use a wheel chair

£ Manual

£ Power/electric

6.3 How do you transfer?

£ I can transfer by myself

£ I can transfer with supervision from someone watching close by

£ I can transfer with physical help from one or two other people

£ I can transfer with a hoist and help from someone

£ I can transfer with a hoist and help from two other people Please write the details here about the help you need for this area:

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6.4 What tasks of daily living do you need help with?

Please write the details here about the help you need for each area in the day and/or night (for example, set up, verbal prompting, supervision, physical assistance from one person or two people, etc).

Please note: you may need to write ‘I don’t do this task because of where I live’—for example, if you live in a nursing home and the nursing home completes these tasks for you.

� Personal hygiene/toileting:

� Bathing/dressing:

� Meals/eating:

� Medication/medical needs:

� Shopping:

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� Housework/home maintenance:

� Food preparation:

� Budgeting/financial decisions:

� Community life (such as visiting local amenities, joining groups etc):

� Employment/study:

� Planning my day’s or week’s activities:

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6.5 Please list all the equipment you use to increase your independence

6.6 Do you have other medical support needs?

£ Pressure area care

£ PEG management

£ Tracheostomy management

£ Catheter care

£ Other – Please provide details:

6.7 How many hours of 1:1 funded support do you have per day?

Approximate hours per day: (please don’t include group activities or shared support within a group environment)

6.8 How much help do you get from a partner, children, family, friends or other people in your community (such as a neighbour) per day?

Approximate hours per day: Please write the details here about the help that you get (include WHERE these people live):

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6.9 How are your supports currently funded?

£ NDIS

£ State Government Disability (DHHS)

£ Department of Veterans Affairs

£ Public Trustee

£ Compensation scheme – (ie WorkCover)

£ I have no funding support

£ Other – Please provide details:

6.10 What everyday devices do you need help to use?

Please write the details here about the help you need when using everyday devices (eg. set up, verbal prompting, supervision, physical assistance from one or two people)

Please note: you may need to write ‘I don’t use this device because of where I live’—for example, if you live in a nursing home and you have limited choice and control over these everyday devices.

� Laptop/computer:

� Tablet (such as an ipad) or telephone (mobile or landline):

� TV remote:

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� Room temperature remote:

� Alert system (eg fob/buzzer etc):

� Other – Please provide details:

6.11 What home design and technology would you benefit from as a way to live more independently?

£ Emergency communications system

£ Home automation to assist you with opening doors, blinds etc

£ Widened doorframes, spacious rooms

£ Adjusted bench heights

£ Bathroom modifications

£ Ceiling hoist

£ Not sure, I need to know more about this

Please describe in detail any home modifications you think you may need:

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6.12 Do any of these statements describe you?

£ I have trouble controlling my anger

£ I can act out without thinking and regret it later

£ I can swear in situations when I’m not supposed to

£ I can do or say things that make other people feel uncomfortable

£ I have trouble understanding things from other people’s point of view (eg. putting myself in their shoes)

£ I have trouble remembering what people tell me and this can lead to arguments

£ I am unable to tell people exactly what is making me upset

£ Certain words or situations will make me angry

Please describe any issues or behaviours that have made it hard for you to live where you are now:

6.13 Do you have a Behaviour Support Plan that helps you manage these issues?

£ Yes

£ No

Please write a summary here about how you manage these issues:

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6.14 Do you need staff support to be immediately available to you when you are alone or don’t have enough 1:1 support (day and/or night)? ( For example, someone to be at the same location as you, but not necessarily in your apartment or room.)

£ Yes

£ No

Please write here why you need this support:

6.15 How do you manage your funding?

£ Self-management

£ Plan-managed funding*

£ NDIA-managed funding

£ A combination of the above

* If you are Plan-managed, please provide details:

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7. YOUR CURRENT WORK AND SOCIAL LIFE

7.1 Do you do any of the following activities?

Please tick the relevant box and tick which days you regularly attend

£ Work:

£ Volunteer:

£ Study:

£ Day program:

£ Formal group/programs:

£ Other – Please list:

7.2 Do you do any of the following social activities?

Please tick the relevant box and tick which days you regularly attend

£ Visit friends and family:

£ Café/restaurant/pub:

£ Movie/bowling etc:

£ General shopping:

£ Gym/fitness training or group:

£ Other – Please list:

Mon Tue Wed Thu Fri Sat Sun

£ £ £ £ £ £ ££ £ £ £ £ £ ££ £ £ £ £ £ ££ £ £ £ £ £ ££ £ £ £ £ £ ££ £ £ £ £ £ £

Mon Tue Wed Thu Fri Sat Sun

£ £ £ £ £ £ ££ £ £ £ £ £ ££ £ £ £ £ £ ££ £ £ £ £ £ ££ £ £ £ £ £ ££ £ £ £ £ £ £

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7.3 Are you a smoker?

£ Yes

£ No

7.4 Do you have a pet?

£ Yes

£ No

If yes, how many and what type of pet (dog, cat, bird etc):

7.5 Do you agree to the following?

� Some of my NDIS funding will be used to pay for my need for an on-site staff member as a back-up to my other (individual, 1:1) supports

� Some of my NDIS funding will be used to pay for coordination of this back-up support

� The back-up support and coordination will be provided by a service provider who will be initially appointed by Ability SDA.

£ Yes

£ No

£ Not sure; I need to know more about this

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8. YOUR HOUSING JOURNEY

8.1 What other housing have you tried or looked at that hasn’t been suitable? Why?

Please write details here:

8.2 Review for Funding

We recommend that you immediately lodge a request with the NDIA for a ‘change of circumstance’ review so that you can apply to be assessed for SDA in you plan.

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Thank you for completing the Expression of Interest Form for Ability Apartments.

Please return the following to Ability SDA by post or email.

1.Expression of

Intererst Form.

+

2.A copy of your

NDIS plan. +

3.Any allied

health reports to support your

application.

Post

Ability SDA PO Box 971

Mona Vale, NSW 1660

Or

Email info@abilitysda.com.au

SUBMIT FORM

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