Brighter Futures Consulting
Please complete the form below and one of team with be in touch with you very soon.
Use this form to submit a referral to our admin team.
Reason for referral Support CoordinationSpecialist Support CoordinationMusic TherapyPositive Behaviour SupportPsychological services (Cognitive Assessment)
Person being referred This referral is for meThis referral is for someone else
Send a copy of the referral to this email address
NDIS number
NDIS Plan START date
NDIS Plan END date
NDIS Plan Funding (for services requested) Agency ManagedPlan ManagedSelf Managed
Plan Manager name
Plan Manager email
Plan Manager phone
PACE Participant NoYes
Name
Date of Birth
Address
Postal Address
Phone
Email
Country of Birth
Gender MaleFemalePrefer not to sayAnother term (please specify)
Please enter your preferred gender term if required
Indigenous Status AboriginalTorres Strait IslanderBothNeither
Interpreter Required YesNo
If yes, which language?
Communication Spoken language effectiveLittle or no effective communicationOther effective non-spoken communication (eg, communication aid or device)
Organisation
Has the referral been discussed with the person and / or the guardian? YesNoN/A
Can they be contacted regarding this referral? YesNo
Please enter the support coordinator details if applicable
Mobile Phone
Please enter the client representative details if applicable
Relationship ParentSpouse/PartnerGuardianCoSOther
Is anyone at the client’s property known to be aggressive or violent? NoYes
If yes, please describe
Are you aware of risks related to pets or animals on the premises? NoYes
Are there any other factors we should be aware of when visiting this client at home on our own? NoYes
Does the participant have current forensic issues or legal matters? NoYes
Does the participant have a history of self-harm or suicidal behaviour? NoYes
Does the participant have a history of violent behaviour? NoYes
Does the participant have a history of sex offences? NoYes
Does the participant experience violence in the home? NoYes
Are there safety concerns with the participant's accommodation? NoYes
Are there concerns regarding the participant having their basic needs met i.e., food, shelter etc? NoYes
Are there any concerns regarding the participant's financial situation? NoYes
Are there any mental health or behavioural issues (in addition to those discussed above? NoYes
Are there any safety hazards for Brighter Futures Consulting Staff members visiting the family home? Such as dogs, unsafe behaviour? NoYes
Is physical force ever used to prevent, restrict, or subdue the movement of the participant's body? NoYes
Is there any Regulated Restrictive Practice in place within the participant's life/Behaviour Support Plan? NoYes
Please provide details on any above responses as required:
Primary Diagnosis
Medical History
Services involved Accommodation or Home Care SupportDay ProgramSupported EmploymentCommunity AccessTerritory Palliative CareMeals on WheelsPrivate TherapiesRehabilitation ServicesOther services
Please enter the Accommodation Support or Home Care provider name
Please enter the Day Program provider name:
Please enter the Supported Employment provider name:
Please enter the Community Access provider name:
Please enter the Private Therapies provider name:
Please enter the Rehabilitation Services provider name:
Other services involved (please list)
Accommodation Type House/UnitTerritory HousingPrivateRentalGround LevelElevatedOwned/MortgageTownhouseShedGranny Flat
Supported Accommodation Supported Accommodation
Accommodation Type
Contact person
Living Arrangements Lives aloneLives with familyLives with others
Current Mobility Aids No aids usedWalking StickWheelie WalkerScooterManual Wheel ChairPowered WheelchairOther
If other, please specify
Please check the requested services Cognitive Assessment (Psychologist) - (min 15 hours)
Comprehensive assessment of the participant's cognition using both standardised and non-standardised assessments; with a report outlining results and recommendations to assist with any areas of deficit
Positive Behaviour Support
Specialist Behaviour Intervention (11_022_0110_7_3)
Behaviour Management Plan Including Training (11_023_0110_7_3)
Individual Social Skills Development (11_024_0117_7_3)
Behaviour Assessment with Recommendations and Report (from therapy funding where no Improved Relationship Funding)-min 15 hours
Music Therapy
Other
For any other services, please describe.
Please describe the goals you wish to achieve with this referral and provide specific directions
Please list NDIS Goals
Please provide any other information you think we will need
Have any other medical or Allied Health assessments been completed? YesNo
If yes, please email to admin@brighterfuturesconsulting.com.au, or attach below.
Please list any other assessments completed
