PBS Referral Form - Soothing Minds

Person Completing This Form:

Date:

First Name:*

Surname:*

Organisation:

Phone:*

Email:*

Relationship:*

Participant Details:

Title:

First Name:*

Surname:*

Gender:

Male

Female

Unspecified

Date of birth:*

Address:*

Phone:*

Email:*

If Under 18 – What are the Parents’ / Guardians Names:

if not applicable, proceed to the next page

Guardian 1

Title:

First Name:

Surname:

Relationship to the participant:

Phone:

Organisation:

Email:

Guardian 2

Title:

First Name:

Surname:

Relationship to the participant:

Phone:

Organisation:

Email:

Are the parents separated?

Yes

N/A

Is there an Intervention or Family Court Order in Place?

Yes

N/A

Does the participant have a Nominee:

if not applicable, proceed to the next page

Title:

First Name:

Surname:

Relationship to the participant:

Phone:

Organisation:

if applicable

Email:

Who is the emergency contact person:

Title:

First Name:*

Surname:

Relationship to the participant:*

Phone:*

Organisation:

Email:*

Consents:

Does the participant have the capacity to consent?*

Yes

Is the Participant under Guardianship?*

Yes

Name(Guardianship)*

Email Address(Guardianship)*

Is the Participant under Public Trustee?*

Yes

Name(Public Trustee)*

Email Address(Public Trustee)*

Are there any relevant court and/or other orders in place?*

Yes

Please provide details:

Is the participant of Aboriginal or Torres Strait Islander origin?*

Yes – Aboriginal

Yes – Torres Strait Islander

Yes – Both

Do not wish to disclose

Country of Birth:*

Languages spoken at home:

Family / Informal Support (please describe):

Accommodation:*

Live with Family

Live Alone

Supported Independent Living

Other

Details:

Day Activities:

School

Day Options

Supported Employment

Open Employment

Other

Details:

Care Plans:

Mental Health

Mealtime Management

Epilepsy

Incontinence

Other

Details:

About the participant:

Primary Disability:*

Secondary Disability:

Impact of Disability on Mobility:

Impact of Disability on Communication:

Impact of Disability on Learning:

Impact of Disability on Social Interaction:

Impact of Disability on Self-Care:

Impact of Disability on Self-Management:

NDIS Details:

NDIS Plan #:*

NDIS Plan Start Date:*

NDIS Plan End Date:*

Is this your first PBS Plan?*

Yes

Are you happy to provide a copy of your NDIS Plan to Soothing Minds?*

Yes

Upload copy of NDIS Plan

Max. file size: 128 MB.

How is your plan managed?*

Self-managed

NDIA managed

Plan Managed

Combined:

Combined:*

If Plan Managed – who is the plan manager?*

Available Budget

Specialist Behavioural Intervention Support (11_022 : $244.22)

Hours

Behaviour Management Plan and Training (11_023 : $244.22)

Hours

Has Block Funding been applied to the plan?

Yes

List

Funding Period

Months

Funding Amount

Please click the + icon to add a row.

Preferred Days

Monday

Tuesday

Wednesday

Thursday

Friday

Preferred Times

Preference of Therapist

Male

Female

Preference of session location

Home Visit

Soothing Minds Practice

School Visit

Other

Other Preference:

NDIS goal/s for this service:

NDIS goal/s

Behaviours of Concern:

Does the participant have a Positive Behaviour Support Plan?*

Yes

Please provide details of behaviours of concern.

Restrictive Practices*

Yes

Provide details:

Does the participant have a Support Coordinator?

Yes

Provider:*

Name:*

Contact Phone:*

Contact E-mail:*

Other Services Providers:

Name:

Contact details:

Organisation:

Phone:

Role:

Email:

Name:

Contact details:

Organisation:

Phone:

Role:

Email:

Name:

Contact details:

Organisation:

Phone:

Role:

Email:

Risk Assessment and Management

Is there a risk that the participant will be aggressive towards the practitioner?*

Yes – low risk

Yes – high risk

Please describe how this risk can be managed:*

Is there a risk that the participant will be intoxicated?*

Yes – low risk

Yes – high risk

Please describe how this risk can be managed:*

Is there a risk that the participant will engage in inappropriate behaviours towards the practitioner?*

Yes – low risk

Yes – high risk

Please describe how this risk can be managed:*

Is the environment where the participant lives, considered a risk?*

Yes – low risk

Yes – high risk

Please describe how this risk can be managed:*

Are there any other risks the practitioner needs to be aware of?*

Yes

Please describe*

Positive Behaviour Support Referral Form

Person Completing This Form:

Participant Details:

If Under 18 – What are the Parents’ / Guardians Names:

Does the participant have a Nominee:

Who is the emergency contact person:

Consents:

About the participant:

NDIS Details:

Available Budget

NDIS goal/s for this service:

Risk Assessment and Management

You can fill out our easy online referral form

You can talk to one of our receptionists on 08 8448 1106

You can email us with what you need or to find out more