Strive Disability Support Services
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Specialist Behaviour or Therapeutic Support Referral
Specialist Behaviour or Therapeutic Support Referral
Date of referral
1. Participant Details
Participant's First Name
Participant's Last Name
Participant's Date of Birth
Phone/Mobile
Email
NDIS Number
Participant's Address
Address Line 1
Address Line 2
City
State
Postcode
Ethnicity
Interpreter Required?
Yes
No
Mobility Issues?
Yes
No
Require's Transport?
Yes
No
Care Situation
2. NDIS Plan Details
Start Date
Is this the participants first plan?
Yes
No
End Date
How many plans has the participant had?
Do you have a contact person for your NDIS plan? (i.e support coordinator, family member, carer etc.)
Yes
No
First Name (NDIS Contact)
Last Name (NDIS Contact)
Phone Number (NDIS Contact)
Email (NDIS Contact)
Role (NDIS Contact)
Plan Management
Plan Manager First Name
Manager Last Name
Plan Manager Phone/Mobile
Plan Manager Email
Email for Invoices
Plan Management
Agency Managed
Plan Managed
Self-Managed
3. Requested Service
Requested Service
Behaviour Management Plan
Specialist Behaviour Support
Developmental Education
Functional Capacity Assessment
Available hours of behaviour management plan funding
Available hours of specialist behaviour support funding
Available hours of DE / FCA funding
4. Carer / Nominee Details
Carer's First Name
Carer's Last Name
Carer's Date of Birth
Relation to participant
Carer's Phone/Mobile
Carer's Email
Carer's Address
Address Line 1
Address Line 2
City
State
Postcode
Other carer(s)?
5. Diagnosis
Diagnosis
Date Diagnosed?
Diagnosing Clinician(s)
Any Dual Diagnoses
6. Medication
Medication #1
Name of prescribed medication
Prescribing physician
Who administers the medication?
Date prescribed
Management of what condition?
Other information
Medication #2
Name of prescribed medication
Prescribing physician
Who administers the medication?
Date prescribed
Management of what condition?
Other information
Medication #3
Name of prescribed medication
Prescribing physician
Who administers the medication?
Date prescribed
Management of what condition?
Other information
Medication #4
Name of prescribed medication
Prescribing physician
Who administers the medication?
Date prescribed
Management of what condition?
Other information
7. Referrer Details
Self Referred?
Yes
No
Referrer's First Name
Referrer's Last Name
Organisation
Phone
Email
Role
Support Coordinator
Professional
Family Member
Other
8. NDIS & Mainstream Services & Providers Involved Details
Name/Organisation
Name/Organisation
Name/Organisation
Name/Organisation
Name/Organisation
Name/Organisation
Service
Service
Service
Service
Service
Service
Address, Email, Phone Number
Address, Email, Phone Number
Address, Email, Phone Number
Address, Email, Phone Number
Address, Email, Phone Number
Address, Email, Phone Number
Additional Information
9. Known Restrictive Practises
Known restrictive practises (management of behaviours of concern for example holding down, medication management, locking in room, or rules that prevent the participant from doing what they want etc.)
10. Presenting Concerns
Presenting concerns and reason for referral to our service (Behaviours of concern [kicking, biting, pushing etc], needs a PBS [to move or leave hospital or to attend work or school etc], support plan etc)
11. Relevant Assessments
Relevant Assessments (within 18 months) - Please tick assessments that you already have.
Positive Behaviour Support Plan
Support Plan
Functional Assessment
Diagnostic Assessment
Sensory Profile
Psychology Assessment
Speech Assessment
Other
12. Requires Development
Requires Development of:
Positive Behaviour Support Plan
Functional Capacity Assessment
Other
13. Inclusive Service Needs
Strive Disability Support Services is an inclusive provider. We welcome referrals from all participants so please let us know if there are any considerations relating to culture, religion, values, beliefs and sexual expression that we can accommodate:
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Strive Disability Support Services - Port Lincoln
Home
Our Services
Meet The Team
Forms
Participant Feedback Form
Complaint Form
Specialist Behaviour or Therapeutic Support Referral
Support Coordination Referral
Policies
Contact
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