Behaviour Support Referral

Person details

NDIS Number:	Plan start date:	Plan end date:
First name:	Middle name:	Last name:
Gender:	Date of birth:	Country of birth:
Choose an item.	Click or tap to enter a date.
Preferred method of contact	Phone number	Email address
How does the person communicate?	Is the person of Aboriginal or Torres Strait Islander origin?	Does the person receive informal decision-making support from family/friends/advocate?
Choose an item.
Does the person need a translator?	Which language?	Does the person identify as being from a CALD background?
Type of residence:	Length of time residing at this address:

Guardian Details

Guardian appointed by a Tribunal?	Name:	Contact:
Choose an item.

Next of Kin (Emergency) Contact

Title:	First name:	Last name:
Person type:	Email:	Phone number:
Choose an item.

Contact for Information Sharing (e.g., Behaviour Support Plans, Reports, Assessments):

Please specify the authorised contact for sharing sensitive information:

☐ NOK	☐ Guardian

Next of Kin (NOK): Generally, a family member listed as the emergency contact. However, the NOK may not be authorised to access confidential information unless they are also the legal guardian or have explicit written consent from the individual.

Legal Guardian: A Legal Guardian is authorised to receive and share information related to the individual’s care, including Behaviour Support Plans, reports, and assessments. Ensure the guardian’s authority is verified for privacy and confidentiality compliance.

Important: Information sharing must follow privacy and confidentiality policies.

Disability details

Disability	Is this diagnosis recognised by the NDIS?
☐ Yes ☐ No
☐ Yes ☐ No
☐ Yes ☐ No
☐ Yes ☐ No
☐ Yes ☐ No

Participant’s current address

Start date:	Click or tap to enter a date.

Key contacts

Title:	First name:	Last name:
Person type:	Person consulted, if other:	Consulted date:
Choose an item.	Click or tap to enter a date.
Email:	Phone number:

Title:	First name:	Last name:
Person type:	Person consulted, if other:	Consulted date:
Choose an item.	Click or tap to enter a date.
Email:	Phone number:

(If additional key contacts are involved, copy and paste another table)

Mealtime Management

Is there a choking or swallowing problem ☐ Yes ☐ No

If yes, is there a Mealtime Management Plan in place ☐ Yes ☐ No

Is the participant on any antipsychotics, benzodiazepines or anti-epileptic medications ☐ Yes ☐ No

Epilepsy Management

Does the participant have Epilepsy? ☐ Yes ☐ No

If yes, does the participant have an Epileptic Management Plan ☐ Yes ☐ No

Behaviours of concern

Type	Choose an item.
Type	Choose an item.
Type	Choose an item.

Restraints*

Type
Type
Type

Funding Allocation

Support	Funding Allocation (hours)
Specialist Behavioural Intervention Support 11_022_0110_7_3
Behavioural Management Plan 11_023_0110_7_3

Funding

☐ NDIS Managed	☐ Self-Managed	☐ Plan Managed

If Self- Managed or Plan Managed, please provide details for invoices

Name
Email

Funding Periods

Does the plan have funding periods?

Yes	No

If yes, please provide the breakdown

How did you hear about us?

☐ LAC recommendation	☐ Support coordinator recommendation	☐ Friend recommendation

☐ Brochure	☐ NDIS register of Providers (online)	☐ CTMHG Website

☐ Social media	(eg: Facebook)	☐ Search engine search (eg: Google)

☐ Other(please specify) __________________________________________________________________

Referrer Details

Name:
Phone number	Email

Plan Goals (please note goals listed within the NDIS plan are essential for acceptance of the referral)

Is the participant on PACE?

☐ No

☐ Yes (please see details below)

My Provider Endorsement (PACE Participants Only)

All Behaviour Support participants on PACE must endorse us as a My Provider for services to commence.

Participants can endorse us via the following methods:

• By contacting their My NDIS Contact.

• Calling the NDIS National Contact Centre on 1800 800 110

The participant will require the following details for endorsement:

Trading Name: Clear Thinking Mental Health Group Legal Name: The Trustee for The Holding Family Trust Provider Number: 4050009546

Appointment Type
☐ In Clinic ☐ Telehealth

☐ Outreach/Home Visits (please provide additional information below)

Has there been any previous Risk Assessments for the home environment?	☐ No ☐ Yes (please provide copies with your referral)
Does the participant have pets?	☐ No ☐ Yes (please detail type of pet/s below)
Are there other people living within the home environment?	☐ No ☐ Yes (please provide details below)
Is there a history of aggression?	☐ No ☐ Yes (please provide details below)

I understand that:

These records are owned by this organisation.

Information within these records will be shared with other staff within the organisation on and only when staff require the information to carry out their duties.

I can ask to see records and receive a copy.

Records are archived for a set period according to policy and procedure.

I understand that all information obtained will be kept confidential.