Interaction Disability Services - Behaviour & Allied Health Services Referral

Participant Details -

Name:*

Date of Birth:

Gender:*

MF

Living Arrangements:*

With familyOn ownGroup homeOther

If Other, please specify:

Address:*

Phone/Mobile:

Email:*

Diagnosis/Disability (including mental health diagnoses):

Specific Medical Needs/Conditions:

Ethnic Background:

Language Spoken:

Interpreter Required:*

YesNo

If Other, please specify:

Employment:*

Supported EmploymentOpen EmploymentOther

Communication:

VerbalNon-VerbalAugmentativeOther

Details:

Are you completing this form as - *

Name:

Address:

Organisation:

Phone/Mobile:

Email:

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

YesNo

NDIS Plan Details -

Participant has NDIS PlanParticipant does NOT have NDIS Plan

Plan date:

to

Plan Number:*

Support Categories -

Improved Daily Living

Optional Question: To ensure we can meet your goals and needs, please advise the amount allocated in your NDIS Plan for this service.

Amount:

Improved Relationships

Optional Question: To ensure we can meet your goals and needs, please advise the amount allocated in your NDIS Plan for this service.

Amount:

Goals:

Support System -

Any other relevant professionals (e.g. medical or ...):

Presenting Issues -

What are primary presenting issues requiring support? (List most serious behaviours or issues)

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

Restricted Practices?*

YesNoUnsure

If yes, please state:

Risks -

Expected Outcomes -

Expected outcomes from service:

Expected timeframe for receiving service?

Primary Contact Person/ Primary decision maker:*

The ParticipantParent/Person ResponsibleGuardianOther

Name:*

Phone:*

Alternate Phone:

Email:*

Address:

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, as well as Medicare.
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.

How Did You Become Aware of Interaction Behaviour and Allied Health Services? - *

Do you consent to being added to Interactions bi-monthly electronic newsletter?*

Additional Comments & Information:

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 access our service in the future.*

Name:

Date:

Contact:

Our Services

Behaviour & Allied Health

Behaviour & Allied Health Services Form

Participant Details -

Are you completing this form as - *

NDIS Plan Details -

Support Categories -

Support System -

Presenting Issues -

Risks -

Expected Outcomes -

How Did You Become Aware of Interaction Behaviour and Allied Health Services? - *

Consent -

Behaviour & Allied Health Services Offered

Assessment

Consultancy

Therapy

Group Therapy

Training

More Behaviour and Allied Health Information

Behaviour & Allied Health Events

Behaviour & Allied Health Team