I Can Cook Registration - I Can Jump Puddles

Cooking Session*

Contact Name*

Participant Name*

Contact Phone*

Contact Email*

Participant Date of Birth*

Residential Address

Brief overview of NDIS plan/ supports currently in place (any Dietetic input past or current):

Reason for NDIS Plan

Does the participant have previous cooking experience/ group education participation (positive experience, if not, why?):

Any contribution to food preparation as part of routine at home currently? (experience with utensils, equipment etc.)

What would you like to get out of the cooking/ group session?

Specific needs to consider (e.g. seating/ hearing/ sensory/ communication/ socialising/ behaviours of concern / swallowing- texture modification needs)

Is Behaviour Support Plan in Place?*

Yes
No

Is there anything that can cause you to feel agitated or upset?*

What do you do when you feel agitated or upset?

How can we help you when you are feeling agitated or upset?

Any risks to be aware of in regards to being in the kitchen? (working with knifes, being around hot elements etc.)

Any allergies/ food intolerances or foods avoided by participant:

Foods you enjoy/ would like to learn to prepare?

Who will be accompanying you to the session? Advise that guardian needs to remain on site for the session.

From 1-10 how confident are you in the kitchen environment (1-not very confident, 10-very confident)

Please enter a number from 1 to 10.

From 1-10 how comfortable do you feel safely using kitchen utensils?(1-not very confident, 10-very confident)

Please enter a number from 1 to 10.

From 1-10 how confident do you feel to prepare a meal on your own? (1-not very confident, 10-very confident)

Please enter a number from 1 to 10.