How to Write an NDIS Individual Support Plan: Person-Centred Planning Requirements

Support Plan vs NDIS Plan vs Service Agreement

One of the most common areas of confusion for new providers is the distinction between the three key documents in a participant’s file. Each serves a different purpose:

What an Individual Support Plan Must Include

Based on the Practice Standards (Outcome 1.1 — Person-Centred Supports, Outcome 3.2 — Support Delivery, and Outcome 3.3 — Support Planning) and NDIS Commission guidance, an individual support plan should include the following sections:

1. Participant Profile

• Full name, date of birth, NDIS number
• Emergency contacts
• Communication preferences and needs (verbal, non-verbal, Auslan, AAC device, visual supports)
• Cultural and linguistic background
• Strengths, interests, and preferences
• Important relationships and social connections

2. NDIS Plan Goals

List the participant’s NDIS plan goals that are relevant to your service. For each goal, describe how your service will contribute to achieving it. Not all NDIS plan goals will be relevant to your service — a SIL provider may address daily living and community participation goals but not employment goals.

3. Daily Support Routines

Describe the participant’s typical daily and weekly routines, including: morning routine, meal times, medication times, personal care, household tasks, community access, social activities, evening routine, and overnight support requirements. This section guides shift workers in providing consistent, person-centred support.

4. Health and Medical Information

• Diagnoses and medical conditions relevant to support delivery
• Current medications (with link to the Medication Administration Record)
• Allergies and dietary requirements
• GP and specialist details
• Hospital action plan (if applicable)
• Seizure management plan, diabetes management plan, or other condition-specific plans (if applicable)

5. Risk Assessment Summary

A summary of the participant-specific risks identified during intake and ongoing assessment, with reference to the detailed risk assessment forms.

6. Behaviour Support Information

Where the participant has behaviours of concern, the support plan should reference the Behaviour Support Plan (BSP) and specify the strategies staff should use. If the BSP authorises restrictive practices, the support plan should cross-reference the restrictive practice authorisation.

7. Consent and Signatures

The support plan must be signed by the participant (or their nominee/guardian) to confirm their input and agreement. Record the date of signing and the date of next review.

Linking NDIS Plan Goals to Daily Support Activities

This is the most important part of the support plan — and the part most providers get wrong. Auditors do not want to see a list of NDIS plan goals copied from the NDIS plan without translation into specific, observable support actions.

The Goal-Activity-Measurement Framework

For each relevant NDIS plan goal, your support plan should specify:

This framework ensures that every shift worker knows what they should be doing to support the participant’s goals, and that progress can be tracked through shift notes. For support workers writing shift notes that reference participant goals, our free NDIS Notes Rewriter includes a goal selector feature that automatically links notes to the relevant NDIS plan goal.

Risk Assessments Within the Support Plan

The support plan should include a summary of participant-specific risk assessments. Common risk areas for SIL participants include:

• Falls risk: Mobility limitations, environmental hazards, history of falls
• Choking/aspiration risk: Dysphagia, modified diet requirements, mealtime management plan
• Medication risk: Polypharmacy, PRN medications, self-administration capabilities
• Absconding risk: History of leaving the house unsupervised, community safety
• Behaviour of concern: Triggers, de-escalation strategies, restrictive practice authorisations
• Skin integrity: Pressure injury risk for participants with limited mobility
• Mental health: Risk of self-harm, suicidal ideation, psychosocial crisis plan
• Dignity of risk: Activities the participant has chosen that carry risk, with a documented dignity of risk assessment

For each identified risk, the support plan should specify: the nature of the risk, the controls in place (what staff do to manage the risk), the participant’s views on the risk, and the escalation process if the risk materialises.

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Participant Input, Consent, and Cultural Considerations

Participant Input

The Practice Standards require that support plans are developed with the participant, not for the participant. Evidence of genuine participant input includes:

• Documented discussions with the participant about their goals, preferences, and routines
• The participant’s own words used in the plan where possible
• The participant’s preferred name, communication style, and cultural practices reflected in the plan
• Family or nominee involvement where requested by the participant or where the participant has a guardian/nominee
• Evidence that the participant was offered the plan to review before signing

Consent

The support plan must be signed by the participant (or their nominee/guardian where the participant lacks capacity to consent). The consent should confirm that:

• The participant was involved in developing the plan
• The participant agrees with the support approach described
• The participant understands they can request changes to the plan at any time
• The participant has been given a copy of the plan

Cultural Considerations

Under Outcome 1.2 (Cultural Safety), the support plan must reflect the participant’s cultural identity and needs:

• Aboriginal and Torres Strait Islander participants: connection to country, kinship obligations, culturally appropriate communication, involvement of Elders where requested
• CALD participants: language preferences, interpreter needs, dietary requirements, religious observances, culturally specific health beliefs
• LGBTQIA+ participants: preferred name and pronouns, relationship recognition, cultural safety from discrimination
• Religious observances: prayer times, dietary requirements, holy days, religious clothing

Review Process and Ongoing Updates

Scheduled Reviews

Support plans should be reviewed at least every 12 months, aligned with the participant’s NDIS plan review cycle. A support plan review should include:

• Assessment of progress towards each goal
• Update of health and medical information
• Review of risk assessments
• Participant feedback on the quality and appropriateness of supports
• Adjustment of goals, activities, or support approaches based on progress
• Updated consent and signatures

Trigger-Based Reviews

A support plan review should also be triggered by:

• A change in the participant’s NDIS plan (new goals, changed funding)
• A significant change in the participant’s health or circumstances
• A critical incident involving the participant
• A request from the participant, their family, or their nominee
• A change in the participant’s living arrangements
• New information from a specialist, therapist, or medical practitioner

What Auditors Check and Common Failures

Auditor Checklist

• Every participant has an individual support plan in their file
• Support plans are signed by the participant (or nominee/guardian)
• NDIS plan goals are translated into specific, measurable daily activities
• Support plans reflect the participant’s strengths, preferences, and cultural identity
• Risk assessments are included or referenced in the support plan
• Support plans have been reviewed within the past 12 months
• Shift notes reference the goals and activities in the support plan
• Participants confirm they were involved in developing their support plan
• Participants have received a copy of their support plan

Common Failures

Failure 1: Goals copied without translation. The support plan lists the NDIS plan goals verbatim but does not describe how daily support activities address them. A goal like “increase independence” without specific activities, timeframes, or measurement is meaningless to shift workers.

Failure 2: No participant signature. The support plan was developed by staff without documented participant input or consent. This violates the person-centred planning requirements of Outcome 1.1.

Failure 3: Plan not reviewed. The support plan was created at intake and has not been reviewed since, despite changes in the participant’s health, goals, or NDIS plan.

Failure 4: Shift notes disconnected from the plan. Daily shift notes do not reference the goals or activities in the support plan, making it impossible to demonstrate that supports are goal-directed.

Failure 5: No cultural considerations. The support plan for an Aboriginal or Torres Strait Islander participant, or a CALD participant, does not include any reference to cultural needs, preferences, or safety considerations.