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Residential statement:About the residential services you get
Disability Act 2006
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
2 Disability Act 2006
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.
About the residential services you get
Residential Statement 3
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.
About the residential services you get
4 Disability Act 2006
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
Who gave you your residential statement?
Residential Statement 5
Your administrator 3 Yes 5 No
If yes, what is the person’s name
Your guardian 3 Yes 5 No
If yes, what is the person’s name
Other people
• friend • 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.
Who gets a copy of your residential statement?
Please circle:
Please circle
which one:
6 Disability Act 2006
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.
About the money you need to pay to live in your house
Residential Statement 7
The money you pay covers:
• rent. This means paying
money to live in your
house.
• 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.
• telephone bills for when
you make phone calls.
• the bed you sleep in,
your pillow, bed sheets
and doona.
• food and drink.
What the money you pay to live in your house covers?
Please circle
Yes No
3 5
Yes No
3 5
Yes No
3 5
Yes No
3 5
Yes No
3 5
8 Disability Act 2006
The money you pay covers:
• the couch, fridge and dinner
table. There are more examples.
• kettle, plates, knives, forks and
frying pan. There are more
examples.
• other things
What the money you pay to live in your house covers?
Please circle
Yes No
3 5
Yes No
3 5
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
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.
When will you get help?
10 Disability Act 2006
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 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.
About your home
private
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
12 Disability Act 2006
• Your bedroom is your private place. No one can
come inside your bedroom unless you say okay.
• 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
About your bedroom
private
Residential Statement 13
• 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.
About your bedroom
14 Disability Act 2006
Do you have a:
• health plan
• behaviour
management plan
• Other
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
About your support
Please circle
Yes No
3 5
If yes please attach
Yes No
3 5
If yes please attach
Yes No
3 5
If yes please attach
Residential Statement 15
For example:
• Locked doors
• Locked cupboards
• Other
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.
Things that happen in your house that you need to know about
Please circle
Yes No
3 5
If yes please attach
Yes No
3 5
If yes please attach
Yes No
3 5
If yes please attach
16 Disability Act 2006
Other important information about your home
Can you have:
• visitors, for example people
you know coming over to
see you at your house
• visitors for example people
you know coming to have
dinner at your house
• a smoke
• have pets, for example bird,
dog
• other
Please circle
Yes No
3 5
Yes No
3 5
Yes No
3 5
Yes No
3 5
Yes No
3 5
Residential Statement 17
For more information
www.dhs.vic.gov.au/disability
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.
18 Disability Act 2006
Acknowledgments
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