Referral Form Finders Keepers WA

Finders Keepers WA Referral Form

NDIS Service Provider of Core and Capacity Building Supports
Participant Information
Name*

First NameLast Name
Email*
example@example.com
Phone Number
Please enter a valid phone number.Format: 0000 000 000.
Preferred method of contact*
Are there any legal orders in place (Guardianship orders, public trustee, etc)
Address*

Street Address

Street Address Line 2

CityState

Postcode
Gender*
Pronouns*
Date of Birth*

DayMonthYear
Date
NDIS Number*
Plan Start Date*

DayMonthYear
Date
Plan End Date*

DayMonthYear
Date
Are there any Cultural or Language diversities?
Do you have any Allergies?
Do you have any Pets?
Primary Disability
Fund Management*

Plan ManagedSelf ManagedNDIA Managed
Plan or Self Managers Email if required*
example@example.com
Next of Kin/ Guardian/ Alternative Contact
Relationship
Type of Contact
Next of Kin / Guardian / Alternative Contact
Full Name
First Name Surname
Email
example@example.com
Phone Number
Please enter a valid phone number.Format: 0000 000 000.
Do you have a support coordinator or are you a support coordinator? Please provide details below
Name / Company / Contact Details
Other Health Contacts

Please provide other contact persons where applicable
GP Details
Allied Health Details
Please list any other relevant Providers, Medical Professionals, Allied Health Professionals, NDIS Support Coordinators, NDIS Plan Management Agencies involved in the participants care. Please list below those that you allow us to contact, anyone else consent will be gained beforehand:
Which of the following services will be needed for the Participant?

Multiple Selection is available
Employment Supports

SLESFinding and Keeping a JobIn Work SupportMicroenterpriseExplorationPre-Employment Group WorkshopVoluntary Placement SupportOther
Social and Community Access

Accessing the CommunityAssistance Attending Appointments/Social GroupsCommunity EngagementOther
Capacity Building

Life Transition Planning Incl. Mentoring Peer Support and Individual Skill DevelopmentInnovative Community ParticipationIndividual Social Skills DevelopmentTransition through School and to Further EducationSkill Development And Training including Public Transport TrainingCounselling session
Support Coordination

Support Coordination
NDIS Service Goals*
NDIS Plan Funding Category*
Core or Capacity?
Further Details, please include funding allocation for services:*
Additional Information (please tell us about yourself)
Preferences

Help us to make your service more specific for you
When would you like your service to start?*
What would be your ideal days and times for service? Please include preferred shift times where possible.*
What attributes would you like your support person to have? (please provide preferences such as age demographic, cultural backgrounds and gender)
Participant Risk Assessment

Please use the following assessment for participant
Does the participant display any of the following challenging behaviours?*

Physical threats/actionsVerbal threats/actionsAbsconding/Running awayMouthing/Eating inediblesUnwilling to follow instructionOvertly loud or noisyImpulsive/AgitatedNone of the aboveOthers, please specify
Please specify other challenging behaviours:
Are there any plans or behavioural support plan in place to targeting the participants challenging behaviours? *
Does the participant have a history of aggression and violence towards others, including caregivers?*

YesNo
Does the participant have a diagnosed mental illness?*

YesNo
Is the participant currently taking any medication?*

YesNo
If you are taking medication, please list:
Does the participant smoke?*

YesNo
If you smoke, do you smoke inside the home?*

YesNo
Does the participant have a history of substance abuse (illicit drugs/alcohol)?*

YesNo
Does the participant current engage in substance abuse (illicit drugs/alcohol)?*

YesNo
Can the participant effectively communicate their wants and needs to others?*

YesNo
Does the participant currently engage in or have a history of self-injurious behaviours/self-harm?*

YesNo
Is the behaviour of the participant unpredictable? if so, please list deatils below in challenging behaviours*

YesNo
Are there any restrictive practices in effect? If so, please provide details*
If you answered yes to any of the questions above, please provide further details to assist staff.*
Are there any triggers or sensory information we should be aware of?*
Physical Disability Risk Assessment

Please use the following assessment for Physical or Neurological (inc autism) Diagnosis
Does the participant have swallowing difficulty or risks of choking?*

YesNo
Does the participant have a risk of falls?*

YesNo
Does the participant require assistance with communication or use a communication device?*

YesNo
Does the participant refuse to take medication?*

YesNo
Manual handling*

YesNo
Is there any of the below manual handling required?

Vehicle accessTransfersBed repositioningOther
Are there any accidental movements such as

Startle reflexGrabbing, holding, leaningSudden body movementsFalling or trippingOther
If you answered yes to any of the questions above, please provide further details to assist staff.
How did you hear about us?*
I First Name Last Name give permission for FInders Keepers WA to contact me regarding follow-up related to this referral.

Signature Date
Should be Empty:

Finders Keepers WA Referral Form

Participant Information

Next of Kin/ Guardian/ Alternative Contact

Other Health Contacts

Which of the following services will be needed for the Participant?

Preferences

Participant Risk Assessment

Physical Disability Risk Assessment