Refer an NDIS client for Behaviour Support or Therapy

NDIS Services Referral Form

Behaviour Support & Therapeutic Services
Client Contact Information
Client name

First NameLast Name
Level of primary communication
Telehealth appropriate?
Does the client require an interpreter?
What is the client's main language?
Date of birth

DayMonthYear
2 digit day, 2 digit month, 4 digit yearDate
Street address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Suburb
Client contact number
Please enter a valid phone number.Format: 0000 000 000.
Client email (if applicable)
example@example.com
Referrer Contact Details
Your name
Your role
Your contact number
Please enter a valid phone number.Format: 0000 000 000.
Your email address
example@example.com
Key appointment contact details
Please nominate the name and contact details of the best contact person for us to arrange appointments with the client.
Appointment preferences
Please indicate any client preferences for appointments (e.g., preferred day/time, face to face, in PBSS office)
Key information & contact for appointments
Please advise us of any appointment preferences and provide the name and contact details for the person we should contact to arrange an appointment with the client (if not the client).

Service Agreement Information
Referral Date

DayMonthYear
2 digit day, 2 digit month, 4 digit yearDate referral is being made
Funding availability
What are you wanting to gain from the referral?
Please provide brief information about the services being requested. Please note. The NDIA requires reports and support plans for clients funded under Improved Relationships.
Assessments required
Funding stream
NDIS plan start date

DayMonthYear
2 digit day, 2 digit month, 4 digit yearPlease advise when the NDIS plan started
NDIS plan end

DayMonthYear
2 digit day, 2 digit month, 4 digit yearPlease advise when the plan ends or the date of upcoming review
NDIS number
NDIS hours
Please indicate the total hours being allocated for this referral.
Funding Type
Specialist Behaviour Intervention hours
Required for Improved Relationship referrals
Behaviour Support Plan & Training hours
Required for Improved Relationship referrals
Improved Daily Living Hours
Required for psychological therapy referrals
Invoices Paid By
Plan Manager Email
Please note, where funding is managed by a plan manager, an email must be provided for the referral to progress
Please upload the NDIS plan or Request for Service

Cancelof
NDIS referral hours- not active
Please indicate the total hours to be allocated for this referral

Funding Agreement
This form must be completed before PBSS can commence service with the client. Please note that from the time the referral is accepted, a service booking may be made and PBSS will seek payment for services provided. Should there be any concerns regarding funding being available, please contact PBSS as soon as possible to prevent any disruptions to service delivery.
By signing this, you indicate your agreement to this funding agreement

Behaviours of Concern
Please indicate whether the client has any criminal history (including charges, allegations and convictions
Briefly state information about any legal, civil or mental health orders the client is currently/has been subject to.
Does the client pose a risk of harm?
Please indicate whether risk factors related to harm to the client, others or the community are present or not.
Which risks are of most concern?
Is the client at risk of imminent harm to themselves or others?
Current behavioural concerns
Is the client displaying any behaviours that are harmful?
Main behaviour of concern
Please indicate the most concerning behaviour the client displays
Secondary behaviours of concern
Please select any other relevant behaviours of concern
What strategies are currently in place?
Details of behaviours of concern
Please provide further detail about current behaviours of concern, including any historical information.

Restrictive Practices
Is there an authorised BSP already in place?
Please indicate whether there is a current behaviour support plan authorised by the Office of the Senior Practitioner.
Are restrictive practices currently being used?
Please advise whether the client's behaviour is currently being managed under restricitve practices (authorised or non-authorised).
Which restrictive practices are being used?
Please list all restrictions
Please provide contact details for the outgoing/past behaviour support practitioner

Continuous Improvement Information
PBSS is dedicated to innovation and continuous improvement, and we're currently gathering information about the level of complexity of clients being referred with this checklist.

We'd appreciate your time and assistance ticking each box where the item is currently present for the client you are referring to us.

Completing this checkbox is optional, and your referral's assessment and progress will not be impacted should you choose to skip this page.
Are any of these factors relevant to the client you are referring?

NDIS Services Referral Form