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Service Request Form
Deaf Chef Ross
2019-07-12T12:59:15+10:00
Service Request Form
Program Request
About you
Your full name (Client)
*
Name and organisation if you are filling this form FOR a client
Your age
*
Age 13 and over. Parent/guidance/carer is required for under 18.
Type
*
Please select 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
Auslan interpreting for the support people
Auslan interpreting supports can be arranged for parents / guidance / carer or support worker who cannot sign Auslan. This will be necessary for the introduction and program assessment sessions.
Yes
No I can sign Auslan well
Language and culture support
Will you need culture support in your program? ie. An Aboriginal or cultural worker, language interpreting support etc. so everyone understands the discussions.
Culture support worker
Language interpreting support (TIS)
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 program
Yes
No
Your area and state (for the time zone differences)
*
Suburb
State
If the program is delivered in your home or accommodation, is there any risk for the provider?
*
You may have a dog that bites, your house is being renovated, children at home, sick people, or anything that may be a risk for the provider coming to your house. If so, please select yes.
Yes
No
Your NDIS plan
Do you have a NDIS plan?
*
If you need just a quote, go to: https://deafchefross.com/service-quote/
Yes
No
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 (Support 1)
Social and Community Participation (Support 9)
Core funding
Your Program
Individuality
*
Is the program only for you or for a group of people?
Individual (just me)
Group (2 - 5 people)
Group (6 people or more)
When do you want to start your program?
*
Soon - within the next 6 weeks
Booking for later - later than 6 weeks
Which program/s do you want to do?
*
Learn to Cook (develop basic cooking skills)
Healthy Cooking (improve healthy cooking skills)
Talk about Food (improve food knowledge)
Plan weekly meals and snacks
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
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?
*
Visits
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 do you wish / hope to achieve from the your 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?
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Acknowledgement
*
I am a real person filling in this form and I am not a robot, spammer or advertising.
I agree to the acknowledgement
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