Support Plan Template Your Name: My Support Plan Month: Year:
2 Important Information My name is: My address is: My D.O.B is: My indicative budget is: Other funding streams available to me are: (eg. ILF, Attendance Allowance) Allocated social worker, care manager or assessment officer: Team: The people who help me To do my support plan are:
3 Agreement to share your plan with others I agree that my plan may be shared as needed to enable me to receive the support described: Yes Yes, but with limitations No Unable to consent Details of any limitations: You could enter in her if there are any agencies/groups/individuals that you do not wish your Plan to be disclosed to Your signature Date: Date completed Signature of your advocate or proxy Date: Date completed
4 All about me Your personal background (personal and family history, strengths, culture, social network Details: Here is the opportunity to tell us about yourself, which may include, your family, childhood, schooling/education, any important relationships, any work/employment, your culture and religion.
5 The day to day activities and relationships that you most value Details: What is a typical day for you and your routine, for example, time when you get up, personal care, cooking, meal times, social life. Who are the most important people in your life
6 Your main current concerns or difficulties (including how they impact on your life) Details: This is a good place to explain the things in your life which are difficult. This could be things which you would like to do but can t, things you used to be able to do but now cannot without support, how your needs impact on your life and your family and how this makes you feel.
7 Other important information others should know about you Any other information you would like to share, for example, is there anything that you feel people should know about you, eg. do you want someone to be patient with you and be caring, do you have difficulty in expressing yourself and need extra support. Here you can describe how you make decisions and any difficulties you might have with this.
8 Do you have any personal preferences regarding your support or care? Yes No Details: What are your preferences regarding the support and care that you may receive, for example, receiving support from a family member, an agency, a male or female carer, someone from your own culture, someone who is in your age group
9 What s working in my life What s not working in my life List all the things in life which are going well List all the things not going as well as you would like
10 How do I want my life to be. This is where you can list all of the things that you would like to be able to do in your life. This can include things to held your physical health and well-being, your emotional well-being and mental health, Activities of daily living, social well-being.
11 Your most important outcomes for the coming year: Essential..bottom lines.. Put here the things that must happen for the next year
12 What I would like to spend my budget on.. This is where you should list the things that you would buy with your personal budget (you do not need to include prices here, you can write these later)
13 How I will keep safe Your safety and Risk Have you made any choices in this plan that may result in increased risk? Yes No If yes, give reasons and possible consequences: How you will contribute to reducing any risk to yourself or others: What can others do to reduce this risk?
14 Managing Situations that may cause concern If this happens An emergency or crisis occurs Actions to be taken (What you want to happen) By whom (Who is to do this)
15 Your Weekly Timetable What I would like my week to look like Monday Tuesday Wednesday Thursday Friday Saturday Sunday Morning Afternoon Evening Night
16 Who will manage your budget You Your Representative Social Care Other Arrangement (eg.mixed) Names, contact details and relationship of those managing your budget: How you will spend your budget? What will be purchased How much it will cost How often Total cost per year Details