Client Form for Support Person

About the Client
Are you a support person or parent/guidance filling this form for a client?*
- No
- Yes
Support person / parent or guidance full name and position:*
Name Position
Support person / parent or guidance's email address:*
Please include your email address so we can contact you if we have questions about your client
Client's full name*
First Surname

About the Client
Type*
Select all that applies to client
- Deaf or hard of hearing
- Hearing with Auslan skills
- Hearing with no Auslan skills
- Have disability (please go to next question)
Explain how the disability may have an impact on your food and cooking skills.
This will help us to make your program inclusive for your participation, and to advise on assistive equipment you may need. It may help if you have a support person to assist you while we guide them.
How fluent is your Auslan?*
- I use Auslan everyday
- I like speaking and signing
- I need Auslan interpreting or communication support

Your support person
Will you have a support person help you with your programs?*
NOTE: If you are doing the Learn to Cook program online, you may need a support person to support you in the kitchen with guidance from the cooking coach.
- Yes
- No
Your support person's name*
Name
Their contact details (mobile number and email address)*
It is for us to contact them when necessary
Can they sign Auslan well?*
- Yes
- Learning
- Need Auslan interpreting support

Who manages your NDIS plan?*
- Self-managed (you manage it yourself)
- Plan-managed (you have a plan manager)
- NDIA-managed (your plan is managed by the NDIS)
Your Plan Manager's name and organisation?*
eg. TP Records, My Plan Manager, Acquire, Plan Managements, etc.
Name Organisation
Plan Manager's email contact*
This is for us to send them the Service Agreement and invoices
Enter Email Confirm Email
Name of your NDIS Support Coordinator or LAC*
We will need to check with them if you have the funds and supports for your program.
Name Organisation
Their email address*
Make sure the email address is correct or they will not receive it
Enter Email Confirm Email
Their mobile or phone number

Your Program
To see our fees, go to the Services page and scroll down: https://deafchefross.com/service-fees/
Total program quoted (includes non-face-to-face supports)
Choose the program/s that you want to do:*
Note: we have included 2 hours extra time in all quotes in case your program is evening or weekend. Please see our Fees for details on how we charge and claim from the NDIS: NDIS
- Learn to Cook (4 sessions)
- Healthy Cooking - for people who CAN cook (4 sessions)
- Extended cooking program (extra 4 sessions)
- Talk about Food (2-3 sessions)
- Help your Health (2-3 sessions)
- Plan your Weekly Meals & Snacks (1 session)
Total
$ 0.00

Safety for everyone
It is important that everyone feels safe. That involves you, your support person, the people you live with, and the person working for Deaf Chef Ross.
If we visit your house, might there be any safety issues?*
Maybe you have dogs that bite, children, elderly people, renovations, clutter, anything that may be unsafe for the coach? Please see our Home Visit policy for information: Home Visit Policy
- I do not have any safety issues
- It may not be safe - please see notes
- Not having Home Visits (video sessions)
If you selected 'May not be safe', please describe the potential risks:*

Notes for Deaf Chef Ross
If you want to give us more information about you or the program/s you want to do, or have any questions, type it below:
If you want to give us more information about you or the program/s you want to do, or have any questions, type it below:
Do you give Deaf Chef Ross administration the consent to talk with your support team about your program?*
Support team members are all the contacts provided on this form ie. Client, Support person, Support Coordinator or LAC, Plan Manager
- Yes
- I'm not using NDIS
Would you like to receive e-newsletters from Deaf Chef Ross?*
The newsletter comes every 2-3 months with updates on our programs.
- Yes
- No thanks
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Client Program Form