Brighter Futures Referral Form

Date of referral:

Name of referrer:

Organisation:

Phone:

Email:

Has the participant/guardian provided consent for referral?YesNo

Full name:

Date of birth:

Gender:MaleFemale

Phone:

Email:

Address:

Full name:

Phone:

Email:

Address:

Please indicate:Public guardianCommunity guardian

Language:

Interpreter required:YesNo

Preferred method of communication (please tick all that apply):Face to facePhone callText messageLetterEmailVisual (images/videos)Contact with my advocate or representativeOther (please indicate)

Country of birth:

Do you identify as:AboriginalTorres Strait IslanderNon-IndigenousRefugeeAsylum SeekerNot stated

Services Required:Specialist behaviour support hoursBehaviour management plan & training hoursPrevious behaviour support plan (if applicable)Music TherapyOccupational TherapyCommunity accessTransportHousehold tasksSupported independent living (SIL)Specialist disability accommodation (SDA)Support Coordination/Specialist Support Coordination

NDIS number:

NDIS plan start date:

NDIS plan end date:

NDIS fund management: (please indicate) Agency managedPlan managedSelf-managed

Plan manager details: (if plan managed)

Does the participant have current forensic issues or legal matters? YesNo

Does the participant have a history of self-harm or suicidal behaviour?YesNo

Does the participant have a history of violent behaviour?YesNo

Does the participant have a history of sex offences?YesNo

Does the participant experience violence in the home?YesNo

Are there safety concerns with the participant’s accommodation?YesNo

Are there concerns regarding the participant having their basic needs met i.e., food, shelter etc?YesNo

Are there any concerns regarding the participant’s financial situation?YesNo

Are there any mental health or behavioural issues (in addition to those
discussed above?YesNo

Are there any safety hazards for therapists visiting the family home? Such as
dogs, unsafe behaviour?YesNo

Is the participant confined in a room or a physical space at any hour of the day
or night?YesNo

Is the participant prescribed medication for the purpose of influencing their
behaviour?YesNo

Are there any devices to prevent, restrict, or subdue the participant's body?YesNo

Is physical force ever used to prevent, restrict, or subdue the movement of the
participant's body?YesNo

Is the participant restricted to accessing any parts of their environment,
including all rooms in the house they live in, outside, items, or activities?YesNo