www.dhs.vic.gov.au/disability. Published by ... Residential support workers will provide you with help to do the .... Re
Disability Act 2006
Residential statement: About the residential services you get
Accessibility This document is also available on the internet at www.dhs.vic.gov.au/disability
Published by the Victorian Government Department of Human Services, Disability Services Division, Melbourne, Victoria, Australia. September 2007 © Copyright State of Victoria, Department of Human Services, 2007. This publication is copyright. No part may be reproduced by any process except in accordance with the provisions of the Copyright Act 1968. Authorised by the State Government of Victoria, 50 Lonsdale Street, Melbourne.
September 2007 (0070807)
Residential Statement 1
About the residential services you get What is the residential statement about? It is about the house you live in and the help you get to do day-to-day living activities like, making meals, eating and getting ready for work.
Name of the residential service X
Your name X
Address of the house you live in X
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About the residential services you get When does your residential statement start and finish? Start
Finish
When will your residential statement be looked at again Review date
Important information • It is very important that your residential statement is looked at again. • This will help us make sure that you are getting the help you need. • Your residential statement will be looked at again in 12 months. • If something has changed, your residential statement can be looked at before 12 months.
Residential Statement 3
About the residential services you get What the residential service must do for you • Residential support workers will provide you with help to do the things you want and need so that you can enjoy your life. What you must do for the residential service • Pay money to live in your house. This is called a residential charge. • Do things like; making sure you keep your room as neat and as tidy as you can. What other things does the residential statement tell you? It tells you: 1. how long your residential statement is for 2. what residential services you will get 3. how much money you need to pay to live in your house 4. how you will pay this money 5. about the duties and rights of the residential service and you 6. other very important information you need to know. For example, how many people will live with you in your house.
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Who gave you your residential statement? Signature X Name of person X What work does this person do? X Who does this person work for? X Address of the residential service provider X
Telephone number X
Residential Statement 5
Who gets a copy of your residential statement? Please circle:
Your administrator
3 Yes
5 No
3 Yes
5 No
If yes, what is the person’s name
Your guardian If yes, what is the person’s name
Other people • friend
Please circle which one:
• family member
• advocate
What is the person’s name
Important information about who gets a copy of your residential statement • You can tell your residential service provider who you want to give a copy of your residential statement to. • It is your right to choose.
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About the money you need to pay to live in your house How much
When Please circle: • every 2 weeks
• every 4 weeks
• every month
How Please circle:
Important information about the money you have to pay to live in your house. • Your residential service will tell you how much you need to pay. • The money you pay to live in your house is called a residential charge.
Residential Statement 7
What the money you pay to live in your house covers? The money you pay covers:
Please circle
• rent. This means paying money to live in your house.
Yes
No
3
5
• bills, for example power that you use when you turn the lights on. There are other bills like bills for the gas and water you use.
Yes
No
3
5
• telephone bills for when you make phone calls.
Yes
No
3
5
• the bed you sleep in, your pillow, bed sheets and doona.
Yes
No
3
5
• food and drink.
Yes
No
3
5
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What the money you pay to live in your house covers? The money you pay covers:
Please circle
• the couch, fridge and dinner table. There are more examples.
Yes
No
3
5
• kettle, plates, knives, forks and frying pan. There are more examples.
Yes
No
3
5
• other things
Yes
No
3
5
Important information about your residential charge • If you break something you will need to pay more money to get a new one or to fix what you have broken. • The residential charge does not include your ‘personal expenses’. Money to buy things like new clothes and shoes is extra. This money is called ‘personal expenses’.
Residential Statement 9
When will you get help? Please tick: Residential support worker will sleep-over. Residential support worker will work at night. Please tick: Residential support worker Monday to Friday
AM from .................................... to ................................... PM from .................................... to ................................... Please tick: Residential support worker Saturday and Sunday
AM from .................................... to ................................... PM from .................................... to ...................................
Important information about the help you will get • You will also get help to do things outside your house like, going to the football or going to see your doctor.
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About your home You will also get a map with your residential statement. This map will tell you about: • where your bedroom is
• common areas. This means areas of your house that everyone can use private
• private areas in your house. This means you will need to ask permission before you go in these rooms
• smoking areas. These are places people can smoke
• things that make your house safe. For example an alarm or fence.
Important information about your home • The map you get will also show you things like, where your front and back yard is.
Residential Statement 11
Other people who live in your house How many people live in your house? Please circle
1, 2, 3, 4, 5, or _________
How many bedrooms does your house have? Please circle
1, 2, 3, 4, 5, or _________
Important information about other people who may stay at your house Does your house have: Please circle Emergency bed
Yes 3
No 5
Respite bed
Yes 3
No 5
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About your bedroom • Your bedroom is your private place. No one can come inside your bedroom unless you say okay. private
• You can say how you want people to come into your bedroom; for example, you can ask people to knock before they come inside.
Very important information about your bedroom • Sometimes a residential support worker has to come inside your bedroom. • They must have a special reason. They do not have to ask you for your permission. This special reason may be: • to protect your health or safety • to protect the health and safety of other people in your house • they think you have run away from your room
Residential Statement 13
About your bedroom • to fix something quickly, for example your bedroom window • to provide you with the help you need or help that is in your support plan • to use strategies in your behaviour management plan • to use strategies in your treatment plan • a community visitor has come to see what is happening in your house
More important information about your bedroom • Your residential service may show your room to another person. For example a person who needs to fix something. • The residential service needs to tell you 1 day before this happens. This needs to be in a letter.
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About your support Do you have a: • health plan
Please circle Yes 3
No 5
If yes please attach
• behaviour management plan
Yes 3
No 5
If yes please attach
• Other
Yes 3
No 5
If yes please attach
Important information • A plan tells the residential service what kind of help you need and the things you want to do to enjoy your life • If you live in a residential service you may have a plan, for example a health plan or a support plan • If you have just started living in a residential service, you will get help to write up your plan
Residential Statement 15
Things that happen in your house that you need to know about For example:
• Locked doors
Please circle Yes 3
No 5
If yes please attach
• Locked cupboards
Yes 3
No 5
If yes please attach
• Other
Yes 3
No 5
If yes please attach
Important information • You may need to have special conditions to protect your health and safety. • Residential support workers will show you how to do things in other ways so that you will not need these special conditions.
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Other important information about your home Can you have:
Please circle
• visitors, for example people you know coming over to see you at your house
Yes 3
No 5
• visitors for example people you know coming to have dinner at your house
Yes 3
No 5
• a smoke
Yes 3
No 5
• have pets, for example bird, dog
Yes 3
No 5
• other
Yes 3
No 5
Residential Statement 17
For more information www.dhs.vic.gov.au/disability
[email protected]
1300 366 731 9 am – 5 pm Monday to Friday
TTY: (03) 9096 0133 For people who are deaf or have hearing, speech or communication difficulties.
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