Behaviour and Allied Health Services Referral Form

Phone*

Please select* MaleFemaleOther

Participant's Date of Birth*

Living Arrangements* With familyOn ownGroup accommodationOther

Diagnosis/Disability (including mental health diagnosis)*

Special Medical Needs/Conditions*

Ethnic Background*

Languages spoken*

Interpreter required*
YesNo

Currently attending*
PreschoolMainstream schoolSpecial schoolPlaygroupOther

Employment*
Supported employmentOpen employmentNot applicableOther

Communication*
VerbalNon-verbalAugmentativeOther

Are you completing this form as*
The ParticipantParent/guardian responsibleSupport CoordinatorGuardianOther

Is the participant able to consent to making the referral?* YesNo

NDIS Plan Details* Participant has NDIS PlanParticipant does NOT have NDIS Plan

NDIS services can only be provided if you have an NDIS Plan. Alternatively, we can provide Behaviour and Allied Health Services within our Consultancy (fee for service) category. Please provide details of your requirements in the box below and Interaction's Behaviour and Allied Health Services team will contact you to discuss your requirements.

NDIS Plan Start Date

NDIS Plan End Date

NDIS Plan Number

Support Categories - Improved Daily Living YesNo

Improved Daily Living - $ Amount

Please enter a number from 0 to 1000000.

Support Categories - Improved Relationships or Behaviour Support YesNo

Improved Relationships or Behaviour Support - $ Amount

Please enter a number from 0 to 1000000.

What services does the participant currently have in place?*
AlliedOccupational TherapistBehaviour SupportPsychiatristSpeech PathologistNurseCounsellorPsychologistNot applicableOther

What are the primary presenting issues requiring support? Please list most serious behaviours of issue.*

What is the impact of the situation on family, support system and others?*

Restricted Practices?
YesNoUnsure

If there are Restricted Practices, please specify:

Please tick any boxes that relate to the current referral
Physical aggressionVerbal aggressionThreat/aggressionCould lead to placementSexual aggressionDeprivation of supervisionNo clinical supportInjurySubstance abuseSchoolRestraint/hospitalisationSeizureMental healthPolice involvement

Expected outcomes from service*

Expected timeframe for receiving service*

Location of provision of service*
Participant's homeFamily homeOur homeCommunityDaycareRespite/Day ProgramSchoolOther

Primary contact person/primary decision maker* The ParticipantGuardianContact details supplied aboveOther

Phone of primary contact person/primary decision maker:

Email of primary contact person/primary decision maker:

Do you consent to being added to Interaction's electronic newsletter?* YesNo

How did you hear about Interaction's Behaviour and Allied Health Services?* Existing client for other servicesFacebook Interaction/PWS pageFacebook advertisingInteraction/PWS websiteGoogleAdvertisementReferralOther

Primary decision maker / Consent for services. Are you:* The participantParent/persons responsibleGuardianContact details supplied aboveOther

Phone*

Email*

Date*

CONSENT - This information will be used to inform allocation of support, and will be stored securely by Interaction's Behaviour and Allied Health Services team. Should you decide not to choose Interaction, your hard copy documentation will be destroyed. Please notify the team if you would like your soft copy files destroyed also. Otherwise, soft copy files will be retained should you choose to access our services in the future.

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Behaviour and Allied Health Request for Service Form