Extended Families LinC Referral Form

  • LinC Referral Form

  • Thank you for choosing Extended Families Australia's LinC Program to provide skilled, enthusiastic, quality disability support workers for you, or someone you support.

    If you would like more information about our LinC service, including the program flier, this can be found on our website. 

    There you will also find information about other Extended Families' services such as ExtendABLE Online, Plan Management, Support Coordination, and Volunteer Match. 

    We have a belief that everyone should be linked in, included, and connected to their community, but know sometimes a little help is needed. We support people by carefully matching people with a disability to support workers who work with participants to capacity building and community inclusion.

    Capacity building and skill development: Experienced staff work with participants to develop independent living skills with the overall aim of fostering natural relationships and genuine community inclusion. The aim is to support people with a disability to feel valued and contribute to their community in a meaningful way. Focus areas might include working on organisational skills, independence on public transport, social and communication skills, health and nutrition planning and positive behaviour support.

    Inclusion support: Our support workers work with participants to identify interests and goals, and encourage participation in community, social and recreation activities.

    While we are here to provide ongoing, consistent support, our overall aim is to support people to develop the skills and confidence to participate in social, recreational, and vocational activities independently, so that one day, our services are no longer required.

    We're here to help: If you’re unsure about the support you need, talk to us about working out a plan to achieve longer term life and independence goals.

     

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    You may save and return to this form at any time, by scrolling to the bottom and clicking 'save'. You'll be emailed a link to the form to complete at a later date.

    If you have supporting documentation, this can be uploaded at the end of this form.

  • Person Making Referral

  • Relationship to the referred person:*
  • Relationship to participant?
  • Preferred contact method:

  • Note: This referral cannot proceed without informed consent. Informed consent means that the person understands the nature and consequences of the service or program to which they are consenting.

  • Has consent been obtained to fill this form?*

  • As you have selected 'No' to the above question, you have indicated informed consent has not been provided and the referral is unable to proceed.

  • Participant Details

  • Preferred contact method:
  • Gender:
  • Date of birth:*
     / /
  • Is an interpreter required?
  • Is the participant Aboriginal or Torres Strait Islander?

  • Other Contact Details

  • Is there a participant representative, parent or guardian?
  • Relationship to participant?
  • Format: (000) 000-0000.
  • Preferred contact method:
  • Does this person require an interpreter?

  • Emergency Planning

  • Please include details about how we can support you in the event of an emergency. 

    Emergencies might include extreme weather such as floods and storms, extreme heat, bush or building fires, or health risks such as a pandemic. An emergency may occur during the course of supports, or may impact our ability to provide continuous supports. Extended Families will take actions to keep you safe, and will endeavour to adjust supports in response to the environment to ensure you can continue to access the support you require.

    Extended Families staff will follow Emergency Guidelines provided by VicEmergency in the event of an emegency, but will work with you to ensure our responses meet you needs and preferences.

  • Emergency contact details required

  • Plan for leaving my home if it is not safe to stay

  • What transport requirements do you have if you need to leave home? Select all the apply

  • Support Coordinator Details

  • Is there a Support Coordinator?
  • Format: (000) 000-0000.

  • NDIS Information

  • Do you / the participant have an NDIS plan?
  • Start date of plan:
     / /
  • End date of plan:
     / /
  • Select funding category/ies you would like to use:

  • Please note: CB - Improved Daily Living cannot be used to claim transport.

    Extended Families' cancellation policy is 12pm the day prior - shifts cancelled after this time the day before a scheduled shift will be charged to the plan.

  • Select funds management for CORE supports:
  • Select funds management for Capacity Building supports:
  • Format: (000) 000-0000.
  • Will the support worker be required to use their own vehicle for travel?
  • Do you / the participant agree for Extended Families to claim transport costs through the funding category selected above?

  • LinC Specific Information

  • Detailed Support Needs Information

  • Is there a companion card?

  • Please note: any activity expenses (including entry fees for support workers) must be covered by you / the participant.

    If support workers are required to manage or supervise the use of money, receipts for any purchases will be requested, retained and provided to you / the participant representative or other appropriate person at the end of the shift.

  • If money is required during a shift, how is it to be managed?

  • Goals

  • Goals of LinC support
  • What specific skill building areas (if any) does this person wish to develop with a support worker?

  • Supervision and Safety Considerations

  • Can you / the participant be alone without supervision?
  • Are there any safety issues we should be aware of? (i.e., running onto the road, over familiarity with strangers, eating non-food items)?

  • Communication

  • Social and Relationship Skills

  • Dietary Information

  • Do you / does the participant have any swallowing difficulties?

  • Physical Support Needs

  • Is mobility support required?

  • Person Centred Supports

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  • RISK ASSESSMENT

  • Home Safety Check

  • Rows
  • If there are recording devices, please list where they are on the property:

  • Medication and Health

  • Are there any alerts or risks that require treatment/management plans or further assessment?*
  • Select any medical / health plans that are required / in place
  • Will the support worker be required to administer medication?
  • Will the support workers be required to complete specific training?
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  • Emotional and Behavioural Considerations

  • Do you / the participant present with challenging behaviours?
  • Is there a Behaviour Support Plan in place that has been written by a positive behaviour specialist?
  • Does the Behaviour Support Plan include any restrictive practices?
  • Select the restrictive interventions included in the Behaviour Support Plan:
  • Select the behaviours that you / the participant may engage in
  • Restrictive Practices: Frequency - How often will the risk occur
  • Restrictive Practices: If the risk occurs, is anyone likely to be injured or harmed?
  • Restrictive Practices: How serious are the potential adverse outcomes?
  • Self-harm: Frequency - How often will the risk occur
  • Self-harm: If the risk occurs, is anyone likely to be injured or harmed?
  • Self-harm: How serious are the potential adverse outcomes?
  • Emotional Dysregulation: Frequency - How often will the risk occur
  • Emotional Dysregulation: If the risk occurs, is anyone likely to be injured or harmed?
  • Emotional Dysregulation: How serious are the potential adverse outcomes?
  • Verbal Aggression: Frequency - How often will the risk occur
  • Verbal Aggression: If the risk occurs, is anyone likely to be injured or harmed?
  • Verbal Aggression: How serious are the potential adverse outcomes?
  • Physical Aggression: Frequency - How often will the risk occur
  • Physical Aggression: If the risk occurs, is anyone likely to be injured or harmed?
  • Physical Aggression: How serious are the potential adverse outcomes?
  • Destruction of Property: Frequency - How often will the risk occur
  • Destruction of Property: If the risk occurs, is anyone likely to be injured or harmed?
  • Destruction of Property: How serious are the potential adverse outcomes?
  • Wandering: Frequency - How often will the risk occur
  • Wandering: If the risk occurs, is anyone likely to be injured or harmed?
  • Wandering: How serious are the potential adverse outcomes?
  • Other: Frequency - How often will the risk occur
  • Other: If the risk occurs, is anyone likely to be injured or harmed?
  • Other: How serious are the potential adverse outcomes?
  • Should be Empty: