Autism Inclusion Practitioner Request for Service

Please complete this document when referring for Autism Inclusion Practitioner Support.

Autism Inclusion Support is tailored therapeutic support provided by our team of highly skilled allied health professionals designed to empower autistic school aged children.

Practitioner support is delievered weekly in an enviornment suitable for the child, including home, school and in clinic. This may include 1:1 skill building in line with the students NDIS goals, the development of personalised learning resources, individualised programming, attendance in meetings or the creation of therapy programs to help your child apply their skills outside of a structured therapy environment.

If you require any support in completing this form, please contact us on 08 8379 6976.

REFERRAL INFORMATION

Name of person completing the referral form *

Relationship to client *

Address *

Email address of referrer *

Best contact number *

CLIENT INFORMATION

Client name *

Preferred Name & Pronoun (he/him, she/her, they/them)

Date of Birth *

Diagnosis and/or medical conditions *

AUTISM INCLUSION PRACTITIONER BOOKING PREFERENCES

Upon receipt of the completed referral form, unless we need to discuss any of your responses with you first, our Client Relationship Team will develop a Service Agreement for you based on the answers you provide. These are typically blocks of 24 hours and Autism Inclusion Practitioner sessions. Please note that session times are booked in 1.5 hour sessions with a mixture of face-to-face and non face-to face components. The agreement will be sent for your approval, and once approved you will be ready to be offered a suitable vacancy when it arises.

Please provide the below information to assist us in creating your agreement.

Will you be using NDIS funding of paying Fee for Service (out of pocket)? *

NDISFee for Service

If NDIS, how much funding are you able to allocate for this service? *

Please upload your NDIS plan and/ or goals here

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NDIS Number *

Plan Start Date *

Plan end date *

Plan Nominee (responsible person for making decisions about NDIS services on the behalf of the individual)

My Improved Daily Living budget is: *

Self-ManagedPlan-ManagedAgency-Managed

Plan Manager name *

Plan Manager email address *

Is this a PACE plan

YesNoUnsure

Does the client/care team require an interpreter? *

YesNo

If yes, which language?

BLOCK OF SUPPORT

Please identify the number of hours you would like in your block of support: *

24 hours48 hoursOther

Specific hours required *

LOCATION:

Please select where the client will receive support: *

HomeSchoolOnline (telehealth)Other

Specify home adress *

School Name *

School Suburb *

If other, please detail *

Time preferences (select all that apply) *

Any time Specific time/s

Please specify: