Behavioural Therapy - Expression of Interest
Penrith Childcare Services are taking expressions of interest for Behavioural Therapy Services.
Child's full name
*
Child's Date of Birth
*
/
Day
/
Month
Year
2 digit day, 2 digit month, 4 digit year
Date
Child's Gender
*
Female
Male
Prefer not to day
Parent/Guardian Full Name
*
Relationship to Child
*
Address
*
Street Address
Suburb
State
Postcode
Contact number
*
Email
*
example@example.com
Referral Information
Who is completing this form?
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Please Select
Parent/Carer/Guardian
Support Coordinator
GP
School
Advocate
Other
Details if different to Parent/Carer/Guardian (Name and Relationship)
Will you remain the primary contact person?
Yes, contact me for bookings
No, contact the parent/guardian
Have you attended our services previously, or are an existing client for a different therapy at our service?
*
Yes
No
Behaviours and Responses
Risk
*
Risk of harm resulting in injury towards others
Risk of harm resulting in injury towards self
Risk of harm resulting in property damage
Risk of harm resulting in exclusion of activities or places
Risk of harm resulting in vulnerability (unsafe social skills/leaving supports/'running away')
Risk of harm resulting in isolation of social connection (friendships)
Other
On a severity scale of 1-10, what level would you currently rate the severity of behaviours?
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Does your child have a Behaviour Support Plan (current or historic)?
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Yes
No
Are you transitioning from a previous Specialist Behaviour Support Provider?
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Yes
No
Are there any strategies currently being used to keep you child or others safe? (Select all that apply)
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Physical guidance or holding
Locked doors, gates, cupboards, or rooms
Preventing access to certain items or areas
Seatbelts, harnesses, or other equipment to stop movement
Medication used to help manager behaviours of concern
Staff or carers stay within arm's reach at all times
None of the above
Unsure
If you selected any of the above strategies, please provide a brief description (what it is, who implements it)
What locations or services do you believe would benefit form Specialist Behaviour Support (E.g. home and school, after school care, shopping centres, playgrounds etc)
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What medications does your child take currently?
*
Any allergies or medical concerns?
*
Do you or your child have any support, communication, sensory, cultural or accessibility needs that we should consider when delivering services?
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Do you require a translator?
Yes
No
Who are the formal supports in your child's life (E.g. GP, Paediatrician, School, Allied Health etc)
*
Please describe your concerns and goals/outcomes for therapy
*
Diagnosis and Medical Information
Does your child have any formal diagnosis?
*
Yes
No
If yes, please provide details
Any medical conditions impacting participation?
Any allergies or relevant risks?
Availability
What days are preferred?
*
Monday
Tuesday
Wednesday
Thursday
Friday
Preferred times
*
Morning
Afternoon
Afterschool
No preference
Other
Funding
Does your child's NDIS plan have funding under capacity building for 'Improved Relationships' or 'Behaviour Support'
*
Yes
No
Please provide your child's NDIS number
Please provide your child's NDIS Plan Dates
Available funding (under 'Improved Relationships' or 'Behaviour Support'
Funding Type
Self Managed
Plan Managed
Agency Managed
The NDIS rate for Specialist Behaviour Support is currently $252.99 per hour. If you are plan or self-managed then payment will need to be made on the day of service, and an invoice will be sent to you to be reimbursed by your plan manager or the NDIS (if self-managed). Please check your funding amount (under ‘Behaviour Support’ or ‘Improved Relationships’) before booking to ensure there are relevant funds for service. A completed service agreement and consent form will need to be signed before your initial session, and this will be sent to you when a booking is confirmed.
*
I agree to the payment policy
Plan Management type
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Self-Managed Plan NDIS
Plan Managed NDIS
Private Health Care
Medicare
Other
Do you have a referral?
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Yes
No
Do you require an interpreter?
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Yes
No
Does your child currently attend any early education and care services or school?
*
Yes
No
If yes, which service does your child attend?
Are there any behaviours, medical needs or other concerns that could affect the safety of your child, our staff or other clients during the sessions? This may include aggression, running away unexpectedly, self-injury, seizures, severe allergies or other concerns.
*
No
Yes
If yes, please provide brief details
Please attach any reports, referrals, or other relevant documents
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of
Consent
By submitting this form, I agree that Penrith City Council may collect and securely store the information I provide for the purpose of allocating and commencing services. I understand that my information will only be accessed by staff who need it to support service delivery.
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I agree
I agree to be contacted by phone, email, or SMS regarding appointments waitlist updates and service availability
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I agree
I understand that submitting this form places me on the waitlist for services. When an appointment becomes available, Penrith City Council will contact me to offer a booking. I understand that I will have 48 hours to respond to this offer. If I do not respond within 48 hours, I may be returned to the waitlist and contacted again when another appointment becomes available.
*
I understand
I understand that I can request to be removed from the waitlist at any time by contacting the Penrith City Council Allied Health Services team.
*
I understand
Signature
*
Date
/
Day
/
Month
Year
2 digit day, 2 digit month, 4 digit year
Date
Submit
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