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CHRISTIE CENTRE INC.Enter Site Name Here & Add site logo to RHS of CC logo (or remove)
About me
I take medication Photo Consent YES NO
I have seizures I have a seizure management plan Social Media YES NO I have allergies Photo Evidence YES NO I have a BSP with the Office of Senior Pracitioner I have a meal time management plan I have a personal care plan I have an asthma management plan I have ambulance cover
Information sharing YES NO
Date of document :Created by :Reviewed by :
Document No: CCX-XXXX-XX-XXXX © Christie Centre IncThis document is the property of Christie Centre Inc. (ABN 68 554 592 464).
Date: Month, YearRevision No: X Page 1 of 10
Photo
My name is: My Date of Birth is: My core support staff is:
You have permission to share my information with:
CHRISTIE CENTRE INC.Enter Site Name Here & Add site logo to RHS of CC logo (or remove)
About me
Document No: CCX-XXXX-XX-XXXX © Christie Centre IncThis document is the property of Christie Centre Inc. (ABN 68 554 592 464).
Date: Month, YearRevision No: X Page 2 of 10
My disability is
I live at
I live with
My phone number is
My Primary contact person is Their phone number is
My Doctor is Their phone number is
My goals
Medication Summary
Medication Dosage Frequency Required during support time
CHRISTIE CENTRE INC.Enter Site Name Here & Add site logo to RHS of CC logo (or remove)
About me
Document No: CCX-XXXX-XX-XXXX © Christie Centre IncThis document is the property of Christie Centre Inc. (ABN 68 554 592 464).
Date: Month, YearRevision No: X Page 3 of 10
What’s important to me
What I like
What I don’t like
CHRISTIE CENTRE INC.Enter Site Name Here & Add site logo to RHS of CC logo (or remove)
About me
Document No: CCX-XXXX-XX-XXXX © Christie Centre IncThis document is the property of Christie Centre Inc. (ABN 68 554 592 464).
Date: Month, YearRevision No: X Page 4 of 10
CHRISTIE CENTRE INC.Enter Site Name Here & Add site logo to RHS of CC logo (or remove)
About me
Document No: CCX-XXXX-XX-XXXX © Christie Centre IncThis document is the property of Christie Centre Inc. (ABN 68 554 592 464).
Date: Month, YearRevision No: X Page 5 of 10
Things you should know
(1) Allergies
(2) Personal Care
(3) Mobility
(4) Meals and drinks
(5) Transport
(6) Cognitive Abilities
(7) Participation
(8) Community Access
(9) Physical Health
(10)Mental Health
(11)Environment
CHRISTIE CENTRE INC.Enter Site Name Here & Add site logo to RHS of CC logo (or remove)
About me
Zones of RegulationArousal Level Looks Like How To Support Me
1 – Low arousal WithdrawnNumbing of emotionsReduced physical movementDepressive thoughts
Example:
Negative self-talkAppears blank, staring into nothing, no emotional expression.
Example:Talk to personEncourage participation in an enjoyable activity.
2 – Base line Where emotions can be tolerated and information processed
Example:
Can be redirected easilyCan engage in conversationFollows instruction
Example:This is where you refer to proactive strategies.
3 – Medium- High Arousal
May escalate without immediate staff intervention.
Example:
Speech becomes rapid or louderBecomes more animatedBreathing rate increasesPacing
Example:Talk to person about what is happening.Use no more than 5 words in a sentence, words no more than 5 letters. Be firm in your approach.Statements such asOffer a chill out space.
4 – High ArousalHeightened Emotions. Increased sensationsFlooded emotional reactivityHyper vigilantDisorganised cognitive processing.
Example:
Hitting othersScreamingProperty damagePushing others
Example:Ensure safety of person, self and others. Offer a quiet space for the person to self-regulate.Use short, small sentences.Use simple instructionsValidate feelings/emotions
Document No: CCX-XXXX-XX-XXXX © Christie Centre IncThis document is the property of Christie Centre Inc. (ABN 68 554 592 464).
Date: Month, YearRevision No: X Page 6 of 10
CHRISTIE CENTRE INC.Enter Site Name Here & Add site logo to RHS of CC logo (or remove)
About me
OFFICE USE ONLY
Document No: CCX-XXXX-XX-XXXX © Christie Centre IncThis document is the property of Christie Centre Inc. (ABN 68 554 592 464).
Date: Month, YearRevision No: X Page 7 of 10
How to best communicate with me
Brief communication paragraph.
What I say/Do What I may be trying to communicate
What I may need you to do
Other communication needs
CHRISTIE CENTRE INC.Enter Site Name Here & Add site logo to RHS of CC logo (or remove)
About me
Document No: CCX-XXXX-XX-XXXX © Christie Centre IncThis document is the property of Christie Centre Inc. (ABN 68 554 592 464).
Date: Month, YearRevision No: X Page 8 of 10
Funding detailsFunding sourceReview dateContact Person (If known) Phone number:
Person Centred/NDIS Plan
Date of last review
Review date
NDIS Planner/NDIS coordinator Phone number:
CHRISTIE CENTRE INC.Enter Site Name Here & Add site logo to RHS of CC logo (or remove)
About me
Document No: CCX-XXXX-XX-XXXX © Christie Centre IncThis document is the property of Christie Centre Inc. (ABN 68 554 592 464).
Date: Month, YearRevision No: X Page 9 of 10
CHRISTIE CENTRE INC.Enter Site Name Here & Add site logo to RHS of CC logo (or remove)
About me
Document No: CCX-XXXX-XX-XXXX © Christie Centre IncThis document is the property of Christie Centre Inc. (ABN 68 554 592 464).
Date: Month, YearRevision No: X Page 10 of 10