Extended Families LinC Referral Form

Thank you for choosing Extended Families Australia's LinC Program to provide skilled, enthusiastic, quality disability support workers for you, or someone you support.

If you would like more information about our LinC service, including the program flier, this can be found on our website.

There you will also find information about other Extended Families' services such as ExtendABLE Online, Plan Management, Support Coordination, and Volunteer Match.

You may save and return to this form at any time, by scrolling to the bottom and clicking 'save'. You'll be emailed a link to the form to complete at a later date.

If you have supporting documentation, this can be uploaded at the end of this form.

Participant is referrerParticipant representative (including parent, guardian or other informal person)Support CoordinatorProfessional - psychologist, speech pathologist, occupational therapistOther

Note: This referral cannot proceed without informed consent. Informed consent means that the person understands the nature and consequences of the service or program to which they are consenting.

As you have selected 'No' to the above question, you have indicated informed consent has not been provided and the referral is unable to proceed.

Phone callSMSEmailVia representative or guardian

Street Address

Street Address Line 2

SuburbState

Post Code

MaleFemalePrefer not to sayOther

	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?

Living area/sBedroom/sKitchen/sOther

YesNoYes, but there is a support person in the household who can assist

Please include details about how we can support you in the event of an emergency.

Emergencies might include extreme weather such as floods and storms, extreme heat, bush or building fires, or health risks such as a pandemic. An emergency may occur during the course of supports, or may impact our ability to provide continuous supports. Extended Families will take actions to keep you safe, and will endeavour to adjust supports in response to the environment to ensure you can continue to access the support you require.

Extended Families staff will follow Emergency Guidelines provided by VicEmergency in the event of an emegency, but will work with you to ensure our responses meet you needs and preferences.

Emergency Contact #1 is listed above as a representative, parent or guardian, I need to provide 1 contact below.There are no emergency contacts listed on this form, I need to provide 2 contacts below.

Plan for leaving my home if it is not safe to stay

I/my family/carer or guardian has a vehicle for tranportationI require specialised or modified vehicle (such as a maxi taxi)I/my family/carer or guardian does not have a carIf I am receiving services during and emergency, I would like my support worker to transport me in their car if I need to leave homeOther

Street Address

Street Address Line 2

Suburb

Street Address

Street Address Line 2

Suburb

Core - Assistance with Social, Community and Economic Participation (Standard)Core - Assistance with Daily Life (Standard)Core - Assistance with Social, Community and Economic Participation (High Intensity)Core - Assistance with Daily Life (High Intensity)Capacity Buidling - Increased Social and Community ParticipantCapacity Building - Improved RelationshipsCapacity Building - Improved Daily Living

Please note: CB - Improved Daily Living is only available as a short term option. This is to be used in the home only and transport cannot be claimed under this category.

Extended Families Australia is a registered TTP provider. Our rates may change in line with new additions to the Price Guide as they are released.

Extended Families' cancellation policy is 12pm the day prior - shifts cancelled after this time the day before a scheduled shift will be charged to the plan.

Plan managedNDIA managedSelf managed

Please note: any activity expenses (including entry fees for support workers) must be covered by the participant.

Please note, if support workers are required to manage or supervise the use of money, receipts for any purchases will be requested, retained and provided to the participant representative or other appropriate person at the end of the shift.

Independently - no support requiredMoney provided by family, handled by participantMoney provided by family, handled by support workerOther

Support to access the communityIndependence skill buildingPsychosocial support (support people with severe mental illness to improve relationships and increase social and community participation)Support with emotional and behavioural regulationSupport to achieve vocational goals (support to build the skills to obtain and maintain employment)Other

YesNoIn development/waitlisted

For example, NDIS plan (if desired), management plans etc

LinC Referral Form

Person Making Referral

Participant Details

Home Safety Check

Other Contact Details

Emergency Planning

Support Coordinator Details

NDIS Information

LinC Specific Information

Detailed Support Needs Information

Goals

Supervision and Safety Considerations

Emotional and Behavioural Considerations

Communication

Social and Relationship Skills

Dietary Information

Physical Support Needs

Person Centred Supports