Central Coast
Referral Date
Name of Referrer *
Referrer’s Agency
Postal Address
Phone No
Mobile No
E-Mail *
Reason For Referral
Name
Date of Birth
Gender UnansweredMaleFemaleOther
Current Address
Phone Number
Email
Indigenous Status AboriginalTorres Strait IslanderOther
Country of Birth
Language Spoken
Mobile Number
Is this person UnansweredLegal GuardianPerson Responsible
This referral has been discussed with the consumer and/or Guardian/Person Responsible and they have given consent for the referral to be made. * UnansweredYesNo
NDIS #
Plan Start Date
Plan End Date
Plan Nominee
Required Support Ratio Unanswered1:11:21:32:1Other
If other
Support Needs UnansweredLowStandardHighComplex
SIL Funding UnansweredCurrentApplied ForNot Applied For
Plan Management UnansweredNDIAPlan ManagerSelf-Managed
If Plan Managed, Name of Manager
Participants need for 1:1 or greater including hours that required at that level:
Breaking Barriers Disability Services is able to support restrictive practices. Please indicate if consumer is currently approved for or will l require any restrictive practices UnansweredYesNo
Primary
Co-Morbid
Others
Short Term
Long Term
Property Damage
Self-Harm/Suicidal Ideations
Verbal Aggression
Medication Refusal
Physical Aggression
Illicit Drug Use
Alcohol Abuse
Smoker
Police Intervention
Admissions for Behavior
Wandering
Hoarding
Poor Hygiene
Other
Please ensure that any current assessments are sent with this referral (As per the NDIS assessments need to be no older than 12 months)
Medications (CTO)
GP Care Plan
Nutrition & Swallowing
Wound Care
Mental Health OT
Diabetes Care Plan
Ambulatory Assessment
Pain Management
Physical OT
Behaviour Support Plan
Continence Assessment
CHAP Assessment
Attached Documentation
Individual Risk Profile
Consent forms, signed and attached
List of current medications | Health Summary
Mental Health OT Assessment
Prior Assessments
Other OT Assessments
Nutrition & Swallowing Assessment
CTO, If applicable
AVO/CHILD PROTECTION/OFFENDERS REGISTRY, If applicable
CHAP ASSESSMENT (current)
Current Schedules e.g., Medications, Meals, Personal Care.
This referral has been sent to Breaking Barriers Disability Services on behalf of the consumer, consent has been obtained by the consumer and/or guardian/person responsible. I confirm that all information provided within this referral is true and correct.
Referrers’ Name
Date
1 + 2 = ?Please prove that you are human by solving the equation *
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