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?

YesNo
What is the client's main language?
Date of birth*

DayMonthYear
Date
Street address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Suburb*
Client contact number*
Please enter a valid phone number.
Client email (if applicable)
example@example.com
Referrer Contact Details
Your name*
Your role*
Your contact number*
Please enter a valid phone number.
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
Date referral is being made
Funding availability*

NDIS funding currently availableNDIS funding booked out by another providerUnknown
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
Please advise when the NDIS plan started
NDIS plan end*

DayMonthYear
Please 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*

Self-ManagedPlan ManagedNDIA Managed
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

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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*

Clear

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?

PBSS Policies & Important Information
Luke and Jess created PBSS in 2020, turning their shared vision of meaningful behaviour change through evidence-based practice into a team of dedicated clinicians who've been specifically chosen because of their alignment with our values.

At PBSS, our commitment to high service standards never wavers, and we'd rather have a slightly longer waitlist than provide service of even average quality. Though we're not always able to get involved immediately, you can be assured that once we allocate your referral to a clinician, they'll be committed and ready to get on board.

If you've got questions or concerns while your referral is on our waitlist, feel free to get in touch with our Admin Manager, Faye, available during business hours Monday to Friday via email at admin@pbss.net.au or by phone on 0481 709 728.
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NDIS Services Referral Form