Behaviour & Allied Health Services Referral Form

Participant Name*

First

Last

Address*

Street Address

City

State / Province / Region

ZIP / Postal Code

Phone*

Please select:*

Male
Female
Other

Participant's Date of Birth*

Living Arrangements*

With family
On own
Group accommodation
Other

If other, please specify:

Diagnosis/Disability (including mental health diagnosis)*

Specific Medical Needs/Conditions:*

Ethnic background:*

Language/s spoken:*

Interpreter required:*

Yes
No

Currently attending:*

Preschool
Mainstream school
Special school
Day program
Other

If other, please specify:

Employment*

Supported employment
Open employment
Other
Not applicable

If other, please specify:

Communication*

Verbal
Non-verbal
Augmentative
Other

If other, please specify:

Are you completing this form as:*

The Participant
Parent/persons responsible
Support Coordinator
Guardian
Other

If other, please specify:

Person completing this form, please enter:

Street Address

City

State / Province / Region

ZIP / Postal Code

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

Yes
No

NDIS Plan Details:*

Participant has NDIS Plan
Participant 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

Yes
No

Improved Daily Living – $ Amount

Please enter a number from 0 to 1000000.

Support Categories – Improved Relationships

Yes
No

Improved Relationships – $ Amount

Please enter a number from 0 to 1000000.

What services does the participant currently have in place?*

If other, please specify:

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?*

Yes
No
Unsure

If there are Restricted Practices, please specify:

Please tick any boxes that relate to the current referral*

Expected outcomes from service:*

Expected timeframe for receiving service:*

Location of provision of service:*

Interaction Office
Family home
Own home
Group home
Daycare
Respite/Day Program
School
Other

If other, please specify:

Primary contact person/primary decision maker:*

The Participant
Guardian
Other
Contact details supplied above

Name of primary contact person/primary decision maker:

First

Last

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?*

Yes
No

How did you hear about Interaction's Behaviour and Allied Health Services?*

Existing client for other services
Facebook Interaction/PWS page
Facebook advertising
Interaction/PWS website
Google
Advertisement
Referral
Other

If other, please specify:

Primary decision maker / Consent for services. Are you:*

The participant
Parent/persons responsible
Guardian
Other
Contact details supplied above

If other, please specify:

Name*

First

Last

Phone*

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.

Phone

This field is for validation purposes and should be left unchanged.

Behaviour & Allied Health Services Referral Form

Behaviour and Allied Health Request for Service Form