Request For Service - Behaviour Support

Before you commence this Request for Service, please note:

Due to initial engagement tasks and the time that is necessary to meet mandatory legislative obligations, we are
unable to accept referrals unless there is a minimum of 70 hours available for 12 months for Behaviour Support.

Participant's Details

First Name *

Middle Name

Surname *

Preferred Name

Date of Birth *

Age

Gender *

Pronouns *

Please describe if "other" was chosen in "Gender"

Participant's Address *

Participant's Email Address *

Participant's Mobile Telephone Number *

Emergency Contact Name *

Emergency Contact's Relationship to Participant *

Emergency Contact's Telephone Number *

Emergency Contact's Email Address *

Do you/does the participant identify as part of the gender and sexually diverse (often known as LGBTQIA+) community? *

Are you/is the participant from an Aboriginal or Torres Strait Islander background? *

Are you/is the participant from a Culturally and/or Linguistically Diverse background? *

Language *

Interpreter Required *

Consultant Preference *

MaleFemaleNo Preference

Service Request Details

Who is making this referral?

Referred By: *

Referrer's Name *

Relationship To Participant *

Referrer's Organisation *

Referrer Address

Referrer Contact Telephone number *

Referrer Email Address *

Service Request Consent

Who is providing consent to this request? *

Plan Nominee Name *

Guardian Name *

Please Note: A Support Coordinator is not considered an Authorised Representative.

Authorised Representative Name *

Authorised Representative Type *

Contact Details

Parent / Family / Informal Supports / Other

Contact 1 - Name

Contact 1 - Relationship to Participant

Contact 1 - Address

Contact 1 - Telephone Number/s

Contact 1 - Email Address

Contact 2 - Name

Contact 2 - Relationship to Participant

Contact 2 - Address

Contact 2 - Telephone Number/s

Contact 2 - Email Address

Service Request and Funding Information

NDIS Number *

Current NDIS Plan Start Date *

Current NDIS Plan End Date *

It is important that remaining amount of funds for
the service you are requesting is recorded in this section.
Please DO NOT record the amount ALLOCATED in current NDIS Plan.

Please refrain from recording N/A (Not Applicable).

If you are unsure of how much funding remains,
you can obtain this information from your NDIS portal
or by calling the NDIS directly on telephone 1800 800 110 .
Failure to provide correct and current funding information in this section
may result in Guidestar being unable to accept your Request for Service.

Service Type / Service Category / Line item number *

SBIS - Specialist Behavioural Intervention Support - 11_022_0110_7_3BMP – Behaviour Management Plan - 11_023_0110_7_3

SBIS - Remaining Funding Available in current plan *

SBIS - Remaining Hours Available in current plan *

BMP - Remaining Funding Available in current plan *

BMP - Remaining Hours Available in current plan *

How will support be paid? (Please Choose One) *

Please advise if NDIS plan is on PRODA or PACE *

PRODAPACE

Plan Management Provider Name

Plan Manager Invoice to be emailed to *

Participant Nominee Name (if applicable)

Self Managed/Participant nominee invoice to be emailed to *

I have checked the appropriate portal or called the NDIA. I confirm that the current funding and hours available recorded on this form are true and accurate. I understand that if information is incorrect, Guidestar may be unable to proceed with this referral until accurate funding information is provided.

Service Agreement and Consent

Guidestar's Service Agreement and Consent Forms are sent via our client management system for electronic signing.
If this request for service is accepted, please advise:

Person who will be signing Service Agreement and Consent *

Please provide email address to send Service Agreement and Consent to *

Please Note: A Support Coordinator is not considered an Authorised Representative

Please provide Authorised Representative's full name *

Please provide Authorised Representative's legal relationship to client *

Please provide Authorised Representative's email address to send Service Agreement and Consent to *

Purpose of Support / NDIS Goals

Summary of reason for referral and expected outcomes *

Presenting Behaviour

Describe the issue/behaviour (please check any/all boxes that are applicable and add a description below, e.g., self-injury, fire lighting, substance misuse, suicidal ideation, etc.) *Please add further details below

Further details *

Risks and Impact

Negative Impact on others

Loss or reduction in services

Increase in the severity/frequency of behaviour

Supporting Participant Information

Relevant Diagnoses *

Physical Support Needs (ie., equipment, etc.) *

Communication (i.e., sign, use of visuals, etc.) *

Who is in this person’s life? (i.e., key relationships/support, including family support system) *

Current living situation (i.e., family home, residential unit, etc.) *

Activities (i.e., programs, employment, respite, etc.) *

Current advocate/previous advocate involvement *

Recent or upcoming changes (e.g., housing, changing services, trauma, forensic involvement, etc.) *

Current or previous involvement with (choose any/all that apply) *

Forensic/JusticeChild ProtectionDrug & Alcohol ServicesNot Applicable

Is there are formal guardian? *

YesNo

Please provide details

Is there an informal guardian? *

YesNo

Please provide details

Please provide any further details below

Health and Other Supports

Are any of the following engaged?

Direct Support ProviderSupported Independent LivingDay ProgramTransport Service

Direct Support Provider Details *

Supported independent Living Details *

Day Program Details *

Transport Service Details *

Are any of the following supports involved or were involved in the past? Please provide details

General Practitioner - Name

Currently or Previously involved?

CurrentPrevious

General Practitioner Clinic Name

General Practitioner Contact Details (if known)

Mental Health Support - Name