Behaviour Support Referral Form

Please complete this document when referring for Behaviour Support services.

Upon receipt of your 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 24hrs, however, assessments alone may be less hours. The agreement will be sent for your approval, and once approved you will be ready to be offered a suitable vacancy when it arises.

If you would like any assistance with completing this form, please contact our team on 08 8379 6976 or at contactus@autismsa.org.au

REFERRAL INFORMATION

Name of person completing the referral form *

Relationship to client *

Email address of referrer: *

CLIENT INFORMATION

Client name *

Preferred name (if different to above)

Date of birth *

Primary contact Phone number *

Primary contact email address *

Primary contact name (if different from client)

Pronouns *

He/himShe/herThey/themOther

Other

Preferred terminology *

autistic/autistic personperson with autismperson on the spectrum/ autistic spectrum Other

Other

Diagnoses *

Autism spectrum disorderAttention deficit hyperactivity disorderIntellectual disability/global developmental delayOther

Other

Do any of the following apply to the client?

Under Guardianship of the MinisterFoster family/alternative care arrangementCourt orderVoluntary out of home care / supported independent living2:1 support requirement

Please provide relevant further details.

BOOKING INFORMATION

What funding stream will you be using? *

NDIS Improved RelationshipsNDIS Improved Daily LivingFee for service (out of pocket)

NDIS number *

Plan Start Date *

Plan End date *

I am *

Plan ManagedSelf ManagedAgency Managed

Plan Manager Name *

Plan Manager email address *

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

Please attach a copy of your NDIS plan

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Please provide name of School *

Please provide location for Program *

Time preferences (select all that apply) *

Any timeSpecific time/ - provide below

Specific times *

BEHAVIOURS OF CONCERN

Other - please specify

For the behaviours selected above, where do they typically occur? (select all that apply) *

HomeSchool/Day options programCommunityOther

Other - please specify

What restrictive practices are currently being implemented (if any)? *

Please provide any relevant details

Does the client have a current Positive Behaviour Support Plan? *

YesNo

If yes, please upload a copy of the plan

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COMMUNICATION

Please provide details here

Does the client/care team require an interpreter? *

YesNo

If yes, which language?

GOALS

What are the client’s goals and expectations for this service?

What are the referring person’s goals and expectations for this service?

SERVICES AND SUPPORTS

Other

ADDITIONAL INFORMATION

Please provide any other relevant information below:

Please upload any relevant documents below (e.g., assessments or reports) if available

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Attachment 2

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Attachment 3

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