Service Request Form

Service Request FormDeaf Chef Ross2019-07-12T12:59:15+10:00

Service Request

About you
Participant's name*
Your full name and organisation if you are filling this form FOR a participant
Your age*
Preferably age 16+ for the cooking program. If you are under 16, parent/guidance may be necessary.
Type*
Please state if you have any physical, sensory, psychiatric, neurological, cognitive and intellectual disability
- Deaf or hard of hearing
- Have disability
- Hearing
Can you communicate in Auslan?*
Ross is deaf and uses Auslan to communicate with clients. He can be very clear and will pace his signing for people who are hard of hearing or learning Auslan.
- Yes I use Auslan every day
- I'm learning Auslan
- I prefer to speak and lipread with signs/gestures
- No I cannot sign at all (select interpreting below if required)
- I will need Auslan interpreting
How is your English reading skill?*
Example: can you read and understand food information, recipes and cooking instructions?
- Good
- Limited
- Prefer Auslan
Do you have any safety concerns?*
It is important for Ross to be aware of any safety concerns you may have in the kitchen
- Health (epilepsy, heart issues, fainting, etc)
- Behavioural (jerking, twitches, sudden changes, etc)
- Other
- No health concerns
Do you have a support worker or carer?*
Select Yes if you need them to help/guide/do tasks for you in the cooking program
- Yes
- No
Your area and state (for the time differences)*
Suburb State
Your NDIS plan
Do you have a NDIS plan?*
- Yes
- No
- Quote for my NDIS plan
If yes, how is your NDIS plan managed?
- Self-managed (I'm managing my plan)
- Plan-managed (I have a plan manager)
- NDIS agency-managed (My NDIS agent is managing my plan)
Do you have the goal in your NDIS plan for the service?
Choose the one that is in your plan or explain in 'Other'.
- Develop my cooking skills
- Improve my food and cooking skills
- Improve my healthy eating diet
- Nothing related to food and cooking
Your NDIS Supports
Do you have these supports in your NDIS plan? Please select the ones you have.
- Assistance with Daily Life - Household Tasks 0120
- Innovative (Social and Community Participation) 0116
- Interpret/Translate food and cooking information 0121
Your Program
Individuality*
Is the program only for you or a group of people?
- Individual (just me)
- Group (2 - 5 people)
- Group (6 people or more)
When do you want to start your food and cooking program?*
If this is for a quote, please go to: https://deafchefross.com/service-quote/
- Soon
- Booking for later
Which food and cooking program you want to do?*
- Learn to Cook (develop basic cooking skills)
- Healthy Cooking (improve healthy cooking skills)
- Talk about Food (improve food knowledge)
- Workshop (for groups)
What are the knowledge and skills you want to achieve from the program?*
- Understand about healthy and unhealthy food
- Food preparation and cooking dishes
- Safe kitchen management tasks
- Store & reheat foods safely
- Plan weekly meals and snacks
How often do you want to do the program?*
They will depend on your location, type of program and the delivery.
- 4 days x 2 hours (standard)
- 4 days x 1.5 hours
- 2 days x 4 hours
- 1 day x 6 hours
- By appointment (flexible)
- Other preference (please explain)
How do you want your program delivered?*
- Personal visits (preferably for the cooking program)
- Video conferencing
- Both
If we use videoconferencing, is your internet service suitable for clear communication?*
It is important that we have a good connection for interaction and program delivery online
- Yes
- Sometimes
- No / Don't have internet
What are the dishes that you want to learn about, prepare and cook?
- Breakfast
- Lunch
- Dinner
- Dessert
- Snacks
What are your aims you want to achieve from the food and cooking program?
How did you learn about Deaf Chef Ross?
- Website
- Your service or support worker
- Family or friend
- Facebook or social media
- Other
Your email address*
Your mobile number*
Video call introduction*
What types of video calling software do you prefer to use? FaceTime, Skype, Zoom, Duo, IMO or other
Video call type? Your ID name or number?
Subscribe to Deaf Chef Ross e-news
- Tick here if you would like to receive e-news from Deaf Chef Ross
Acknowledgement*
I am a real person filling in this form and I am not a robot, spammer or advertising.

I agree to the acknowledgement
CAPTCHA

Save and Continue Later

Video call type?	Your ID name or number?

Service Request Form

Service Request

About you

Your NDIS plan

Your Program

Subscribe to Deaf Chef Ross e-news