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Behaviour Support Referral Form

Complete this form to request Behaviour Support services. The fields below follow the structure from your Behaviour Support PDF.

1. Referrer Information

2. Participant Details

Interpreter required
Preferred option for communication
Do you identify as Aboriginal and Torres Strait Islander?
Is there a plan nominee, child representative, guardianship and/or administration order in place?

3. Participant Representative Details (if relevant)

4. Services Required

5. Restrictive Practices

Are there restrictive practices in place?

6. Current Behaviours of Concern

7. Primary and Secondary Diagnosis

8. Reason for Referral

9. Participant Goals

10. Risks and Safety

The participant is at risk of:

Are there any court orders applicable?

Please ensure these are made available upon referral (e.g. parole, apprehended violence order etc.)

Has the participant been physically aggressive towards allied health, medical or support staff?
Has the participant been incarcerated in a prison, juvenile detention center or spent time in a forensic hospital for a violent or sexual offence?
Is the participant currently engaging in alcohol or drug use?

11. Other Information

Is there any other information we need to know about the participant?

e.g. are there any topics that may trigger the client to become upset? Any specific likes or dislikes?

12. Initial Assessment

Has the participant had previous behaviour support?
Preference for delivery method
Frequency of delivery
Are there any culture requirements?

13. Service Agreement

Who will sign the service agreement

If a recommendation report is required and you do not have Improved Relationship Funding, would you like to use funding from Improved Daily Living?

14. Payment Method

Who should we invoice

If plan managed, please complete the details below:

15. Additional Information

Myxa