WITHOUT ASSISTANCE I AM ABLE TO, Please circle best response:
• manage all of my day-to-day personal care activities Always Usually Sometimes Never
eg. shower, dress, groom, toilet, maintain personal hygiene
• manage all of my own mental health care needs Always Usually Sometimes Never
eg. remember medications, attend appointments, complete scripts
• manage all of my own Physical Health care needs Always Usually Sometimes Never
eg., manage health conditions, dental care, attend appointments
• remain safe throughout the day Always Usually Sometimes Never eg avoid hazardous situations in home/community, avoiding criminal behaviour,
falls risk, safe ‘drinking/drug taking’, turn appliances off
• set Personal Goals and maintain Direction in life Always Usually Sometimes Never eg. plan daily activities, set future goals, save for a holiday, pursue a career, a sense of purpose
• complete all of my Household Responsibilities Always Usually Sometimes Never
eg. clean, garden, cook, maintain home, go shopping, maintain vehicle
• maintain employment, education and/or training roles Always Usually Sometimes Never
• maintain my interests and hobbies Always Usually Sometimes Never
• successfully manage my own finances Always Usually Sometimes Never
eg. pay bills, save money, pay rent, budget, set up bank accounts
• organise my own daily routines & activities Always Usually Sometimes Never
eg. get places on time, make daily decisions, remember tasks, get out of bed on time
• manage my caring roles/responsibilities Always Usually Sometimes Never
eg. parent children, look after pets, support/care for parents
• maintain a productive Relationship with my Family members Always Usually Sometimes Never
eg. family contact & support, relationship with your partner, relationship with your children
• maintain productive social Relationships with Friends/acquaintances Always Usually Sometimes Never
eg. maintain contact with friends, attend social events, meet new people
Always Usually Sometimes Never• effectively participate in the community
eg. participate in community/social groups, follow directions and rules, engage with public
• understand and communicate using speech and language Always Usually Sometimes Never
Always Usually Sometimes Never
- understand and communicate using non-verbal means For questions about use of this form refer to the usage guidelines or contact Jason.mortimore@act.gov.au Page 1 of 2
• adjust to ‘Life Changes’ and ‘Life Stressors’ Always Usually Sometimes Never
eg. move home, a new job, new Doctor, lose a friend, new housemate, wake late, manage crowds
• develop new skills for living independently Always Usually Sometimes Never
eg. cooking skills, internet use, catching bus to new place, a new job, new living arrangements
• effectively access the community Always Usually Sometimes Never
eg. drive a vehicle, catch public transport, ride and/or walk places
• effectively manage physical tasks Always Usually Sometimes Never
eg. walk, sit for periods, lift objects, stand, balance,
NDIS Applicant’s Name: (a self report questionnaire regarding the applicant’s perceived function)
For questions about use of this form refer to the usage guidelines or contact Jason.mortimore@act.gov.au Page 2 of 2