Extended Families LinC Referral Form

Please answer Yes or No to the below:

	No	Yes
Working smoke alarms
Household members smoking inside
Evidence of illicit substances
Dangerous breed or untrained dog?
Hazards in access to property
Issues of exit in case of fire
Other residents/visitors who may pose a risk
Evidence of firearms/weapons
Manual handling risks
Issues related to infectious illness (ie COVID-19)
Likelihood of exposure to hazardous waste or infectious material?
Does the house have CC-TV Cameras, or any other recording device inside?

If there are recording devices, please list where they are on the property:

Living area/sBedroom/sKitchen/sOther

Provide details of 'other' risks or safety issues that may be relevant:

Are there any alerts or risks that require treatment/management plans or further assessment?*

YesNo

Select any medical / health plans that are required / in place

Please provide details, including how the risk/s are managed.

Will the support worker be required to administer medication?

YesNo

List type of medication (a medical administration form will be required):

Will the support workers be required to complete specific training?

Attach medical treatment plans here

Do you / the participant present with challenging behaviours?

YesNoPreviously, but now well managed

Please describe identified triggers:

Is there a Behaviour Support Plan in place that has been written by a positive behaviour specialist?

YesNoIn development/waitlisted

Does the Behaviour Support Plan include any restrictive practices?

YesNo

Select the restrictive interventions included in the Behaviour Support Plan:

Select the behaviours that you / the participant may engage in

Please describe any behaviour management strategies you / the participant uses:

Restrictive Practices: Describe the restrictive interventions used - what happens when they are required

Restrictive Practices: When is the risk most likely to occur?

Restrictive Practices: Frequency - How often will the risk occur

Low - Once every 6 to 12 monthsMedium - Once per monthHigh - Once per weekVery High - Once per day / multiple times per day

Restrictive Practices: If the risk occurs, is anyone likely to be injured or harmed?

YesNo

Restrictive Practices: Who is likely to be injured or harmed?

Restrictive Practices: What kinds of injury or harm is likely to occur?

Restrictive Practices: How serious are the potential adverse outcomes?

Low: Minor injury, no medical intervention required, quickly resolved same day.Medium: More severe injury, medical intervention required, resolved within 2-3 days.High: Severe injury, emergency services required, longer term recovery. Potential for psychosocial harm, potential for disruption to living situation.Very High: Permanent injury or death. Long term psychosocial harm. Long term instability in living situation.

Self-harm: Describe the behaviour - what happens when the behaviour occurs

Self-harm: When is the risk most likely to occur?

Self-harm: Frequency - How often will the risk occur

Low - Once every 6 to 12 monthsMedium - Once per monthHigh - Once per weekVery High - Once per day / multiple times per day

Self-harm: If the risk occurs, is anyone likely to be injured or harmed?

YesNo

Self-harm: Who is likely to be injured or harmed?

Self-harm: What kinds of injury or harm is likely to occur?

Self-harm: How serious are the potential adverse outcomes?

Low: Minor injury or harm, no medical intervention required, quickly resolved same day.Medium: More severe injury or harm, medical intervention required, resolved within 2-3 days.High: Severe injury, emergency services required, longer term recovery. Potential for psychosocial harm, potential for disruption to living situation.Very High: Permanent injury or death. Long term psychosocial harm. Long term instability in living situation.

Self Harm: Proactive strategies to prevent risk occurring

Self Harm: Early intervention strategies when early warning signs begin / to prevent further escalation

Self Harm: Reactive response strategies when behaviour is occurring / has escalated

Emotional Dysregulation: Describe the behaviour - what happens when the behaviour occurs

Emotional Dysregulation: When is the risk most likely to occur?

Emotional Dysregulation: Frequency - How often will the risk occur

Low - Once every 6 to 12 monthsMedium - Once per monthHigh - Once per weekVery High - Once per day / multiple times per day

Emotional Dysregulation: If the risk occurs, is anyone likely to be injured or harmed?

YesNo

Emotional Dysregulation: Who is likely to be injured or harmed?

Emotional Dysregulation: What kinds of injury or harm is likely to occur?

Emotional Dysregulation: How serious are the potential adverse outcomes?

Low: Minor injury or harm, no medical intervention required, quickly resolved same day.Medium: More severe injury or harm, medical intervention required, resolved within 2-3 days.High: Severe injury, emergency services required, longer term recovery. Potential for psychosocial harm, potential for disruption to living situation.Very High: Permanent injury or death. Long term psychosocial harm. Long term instability in living situation.

Emotional Dysregulation: Proactive strategies to prevent risk occurring

Emotional Dysregulation: Early intervention strategies when early warning signs begin / to prevent further escalation

Emotional Dysregulation: Reactive response strategies when behaviour is occurring / has escalated

Verbal Aggression: Describe the behaviour - what happens when the behaviour occurs

Verbal Aggression: When is the risk most likely to occur?

Verbal Aggression: Frequency - How often will the risk occur

Low - Once every 6 to 12 monthsMedium - Once per monthHigh - Once per weekVery High - Once per day / multiple times per day

Verbal Aggression: If the risk occurs, is anyone likely to be injured or harmed?

YesNo

Verbal Aggression: Who is likely to be injured or harmed?

Verbal Aggression: What kinds of injury or harm is likely to occur?

Verbal Aggression: How serious are the potential adverse outcomes?

Low: Minor psychosocial harm, no further intervention required, quickly resolved same day.Medium: Some psychosocial harm, some intervention required, resolved within 2-3 days.High: Severe harm, emergency services required, longer term recovery. Potential for ongoing psychosocial harm, potential for disruption to living situation (participant).Very High: Long term psychosocial harm. Long term instability in living situation (participant).

Verbal Aggression: Proactive strategies to prevent risk occurring

Verbal Aggression: Early intervention strategies when early warning signs begin / to prevent further escalation

Verbal Aggression: Reactive response strategies when behaviour is occurring / has escalated

Physical Aggression: Describe the behaviour - what happens when the behaviour occurs

Physical Aggression: When is the risk most likely to occur?

Physical Aggression: Frequency - How often will the risk occur

Low - Once every 6 to 12 monthsMedium - Once per monthHigh - Once per weekVery High - Once per day / multiple times per day

Physical Aggression: If the risk occurs, is anyone likely to be injured or harmed?

YesNo

Physical Aggression: Who is likely to be injured or harmed?

Physical Aggression: What kinds of injury or harm is likely to occur?

Physical Aggression: How serious are the potential adverse outcomes?

Low: Minor injury, no medical intervention required, quickly resolved same day.Medium: More severe injury, medical intervention required, resolved within 2-3 days.High: Severe injury, emergency services required, longer term recovery. Potential for psychosocial harm, potential for disruption to living situation.Very High: Permanent injury or death. Long term psychosocial harm. Long term instability in living situation.

Physical Aggression: Proactive strategies to prevent risk occurring

Physical Aggression: Early intervention strategies when early warning signs begin / to prevent further escalation

Physical Aggression: Reactive response strategies when behaviour is occurring / has escalated

Destruction of Property: Describe the behaviour - what happens when the behaviour occurs

Destruction of Property: When is the risk most likely to occur?

Destruction of Property: Frequency - How often will the risk occur

Low - Once every 6 to 12 monthsMedium - Once per monthHigh - Once per weekVery High - Once per day / multiple times per day

Destruction of Property: If the risk occurs, is anyone likely to be injured or harmed?

YesNo

Destruction of Property: Who is likely to be injured or harmed?

Destruction of Property: What kinds of injury or harm is likely to occur?

Destruction of Property: How serious are the potential adverse outcomes?

Low: Minor injury, no medical intervention required, quickly resolved same day.Medium: More severe injury, medical intervention required, resolved within 2-3 days.High: Severe injury, emergency services required, longer term recovery. Potential for psychosocial harm, potential for disruption to living situation.Very High: Permanent injury or death. Long term psychosocial harm. Long term instability in living situation.

Destruction of Property: Proactive strategies to prevent risk occurring

Destruction of Property: Early intervention strategies when early warning signs begin / to prevent further escalation

Destruction of Property: Reactive response strategies when behaviour is occurring / has escalated

Wandering: Describe the behaviour - what happens when the behaviour occurs

Wandering: When is the risk most likely to occur?

Wandering: Frequency - How often will the risk occur

Low - Once every 6 to 12 monthsMedium - Once per monthHigh - Once per weekVery High - Once per day / multiple times per day

Wandering: If the risk occurs, is anyone likely to be injured or harmed?

YesNo

Wandering: Who is likely to be injured or harmed?

Wandering: What kinds of injury or harm is likely to occur?

Wandering: How serious are the potential adverse outcomes?

Low: Minor injury, no medical intervention required, quickly resolved same day.Medium: More severe injury, medical intervention required, resolved within 2-3 days.High: Severe injury, emergency services required, longer term recovery. Potential for psychosocial harm, potential for disruption to living situation.Very High: Permanent injury or death. Long term psychosocial harm. Long term instability in living situation.

Wandering: Proactive strategies to prevent risk occurring

Wandering: Early intervention strategies when early warning signs begin / to prevent further escalation

Wandering: Reactive response strategies when behaviour is occurring / has escalated

Other: Describe the behaviour - what happens when the behaviour occurs

Other: When is the risk most likely to occur?

Other: Frequency - How often will the risk occur

Low - Once every 6 to 12 monthsMedium - Once per monthHigh - Once per weekVery High - Once per day / multiple times per day

Other: If the risk occurs, is anyone likely to be injured or harmed?

YesNo

Other: Who is likely to be injured or harmed?

Other: What kinds of injury or harm is likely to occur?

Other: How serious are the potential adverse outcomes?

Low: Minor injury, no medical intervention required, quickly resolved same day.Medium: More severe injury, medical intervention required, resolved within 2-3 days.High: Severe injury, emergency services required, longer term recovery. Potential for psychosocial harm, potential for disruption to living situation.Very High: Permanent injury or death. Long term psychosocial harm. Long term instability in living situation.

Other: Proactive strategies to prevent risk occurring

Other: Early intervention strategies when early warning signs begin / to prevent further escalation

Other: Reactive response strategies when behaviour is occurring / has escalated

LinC Referral Form

Person Making Referral

Participant Details

Other Contact Details

Emergency Planning

Support Coordinator Details

NDIS Information

LinC Specific Information

Detailed Support Needs Information

Goals

Supervision and Safety Considerations

Communication

Social and Relationship Skills

Dietary Information

Physical Support Needs

Person Centred Supports

RISK ASSESSMENT

Home Safety Check

Medication and Health

Emotional and Behavioural Considerations