Banksia Support Enquiry Form

Name*

First NameLast Name
Email*
example@example.com
Enquiry Type*
Please select the nature of your enquiry
Message
Participant Referral Form - Waitlist Only

Please Note: Any new referrals will be placed on our waitlist as we are currently at capacity. Thanks for taking the time to provide this important information for us in your referral. We pride ourselves in doing things well at Banksia; in fact, we are known for it. But this means we may do things a little different than what you might be used to. We believe in partnering with our clients and we don't promise what we can't provide. So, during the intake process, we will look at all this information you provide to ensure we can provide you the best information, based on what you need and what we can provide. This information is kept private and will not be shared with anyone outside of our team. If you have any difficulty, or would like support to complete the form, let us know and we will gladly provide any assistance we can to get this admin task out of the way, so we can get into the real discussions about how we can help you meet your goals. Thanks so much!
Participants Name*

First NameLast Name
Participants Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Participants Phone Number*
Please enter a valid phone number.
Participants Date of Birth*

MonthDayYear
Date
Participants Age (years)*
Participants Gender*

MaleFemaleNon BinaryPrefer not to say
Is the Participant from a Culturally and Linguistically Diverse (CALD) background*

YesNo
Cultural Background*
Are Alternative Methods of Communication Required for the Participant? (eg Audio/Visual/Auslan)*

YesNo
Details of Alternative Communication*
Which service does the Participant require?*

Behaviour SupportEarly Childhood Intervention (0 - 9)
Does the Participant Have an NDIS Plan?*

YesNo
NDIS Number*
NDIS Plan Start Date*

MonthDayYear
Date
NDIS Plan End Date*

MonthDayYear
Date
NDIS Billing Details for "Improved Daily Living" funding*

Self ManagedPlan ManagedNDIA Managed
Plan Manager's Name (Organisation)
Plan Manager's Phone Number
Please enter a valid phone number.
Plan Manager's Email Address
example@example.com
Does the participant also have "Improved Relationships" or "Behaviour Support" funding that they wish to use for Behaviour Support?

YesNo
NDIS Billing Details for "Improved Relationships" or "Behaviour Support" funding

Self ManagedPlan ManagedNDIA Managed
Can you summarise the participants goals in their NDIS plan that you would like us to support to achieve.
Does the Participant have any existing Behaviour Support Practitioners (or have they worked with anyone previously?) Can you provide their name and contact details.
Will you be sending through details of previous assessments to be shared with Banksia Support Services (eg Behaviour Support plans, Psychology, OT, Speech Assessments)*
As the person making the referral, what is your name and your role in the participant's life (and contact details if different to participant)*
Can you summarise why you have chosen to make this referral? What do you need from Banksia and how can we meet this need?*
Which option best describes the legal decision maker for the participant you are referring?*

Parent/Carer- Participant is childParticipant makes own decisionsParent/ Guardian- Participant is adult but no guardianship order in placeOffice of Public Guardian is legal decision makerDCJ- Participant is living in statutory out of home care placementOTHER - Will detail in Intake interview
If the participant is under 18, do they have a Primary Carer*

YesNoParticipant is 18 or over
Primary Carer Name*

First NameLast Name
Primary Carer Relationship to Participant*
Primary Carer Phone (if different to Participant)
Please enter a valid phone number.
Primary Carer Email (if different to Participant)
example@example.com
Primary Carer Address (if different to Participant)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
As participant is 18 or over, do they have a legally appointed decision maker?*

YesNoNot sure
Preferred Contact Method for follow up*

PhoneEmail
How did you hear about Banksia Support Services*

Word of MouthCurrent Provider/PractitionerGoogleFacebookEmail/NewsletterOther
Clinical Supervision
Organisation (if applicable)
Current role/title*
Supervisee Contact number*
Please enter a valid phone number.
Supervisee email *
example@example.com
Discipline/Area of Specialty or training*

EducationAllied HealthSupport WorkerNo formal qualificationsOther
Supervision Type requested*

Individual SessionsGroup SupervisionPeer SupervisionAd hoc/ Consultation
Frequency and Duration*

FortnightlyMonthlyOne offTo be discussed
Preferred session length*

60 minutes90 minutes
Areas of focus - Please tick as many as apply*

Behaviour Support (NDIS)Early Childhood InterventionComplex Case DiscussionTrauma informed practiceSupervision for Provisional/Core level practitionersAlternate Assessment Pathway ApplicationSeeking endorsement through self assessmentBusiness/Private Practice mentoringEthical Decision makingReport writing sign off and complianceOther
Supervision Goals - What are you hoping to achieve through supervision?
Any accessibility needs, language preferences, or other relevant information we should know to support you?
Do you consent to the use of AI-assisted tools during your supervision sessions?*

YesNo
Referral Acknowledgement

I understand that this referral does not guarantee immediate availability and that I will be contacted to discuss options and scheduling.I consent to being contacted by Banksia Support Services in relation to this referral.
Schedule a time to speak with our Director, Amy Hall (optional)
Should be Empty: