NomineeReferral - Interacting Minds

1. What is your name?

2. What is you relationship to the participant?

Support Coordinator

Guardian

Nominee

Behaviour Specialist

3. Does the participant have a nominee or are they their own decision maker?

Nominee

Makes Own Decisions

4. Has the nominee given consent for this referral?

Yes

5. What is your email address?

6. What is your phone number?

9. Participant Home Address

11. Start Date of plan

12. Date of plan review

13. End Date of plan

14. Please select type of funding:

Self Managed

Plan Manager

NDIA Managed

Mainstream Cost Agreement

15. Funding Type:

Improved Relationships

Improve Daily Living

16. Funding Provided ($ or Hours)

18. What is the nominees relationship to you?

Support Coordinator

Guardian

Behaviour Specialist

Other

19. Nominee email address:

20. Nominee phone number:

21. Is the key carer the nominee?

Yes

Other

22. If the participant attends day program, or school, please provide the information:

23. If the participant does attend any of these programs, what professionals are involved?

24. Details of health professional involved:

Why are you making the referral?

25. Please provide a brief description of participant, any relevant Behaviours of Concern / reason for referral.

26. What are the participants clinical diagnosis /diagnoses:

Autism Spectrum Disorder Level 1 - Level 2 - Level 3 - Unknown Level

Attention deficit hyperactivity disorder

Anxiety Disorder (GAD)

Acquired Brain Injury ABI

Bipolar and Related Disorders

Borderline Personality Disorder

Communication Disorder: Please specify in next question

Depression or Depressive Disorder: Please specify in next question

Developmental Delay: Please specify in next question

Hearing Impairment

Minor Intellectual disability

Intellectual disability

Motor Disorders

Physical Disorder: Please specify in next question

Parkinsons Disorder

Parkinsonism

Psychosis / Psychotic Disorder

Psychosocial: Please specify further

Schizophrenia

Specific learning disorder

Traumatic Brain Injury TBI

Vision Impairment

27. Please enter any relevant information about the participants diagnosis below:

28. Please tick Living Situations that apply:

Currently Incarcerated

Currently on Bail or Parole

Currently engage in Justice or Pre sentence services such as legal aid

Previously was incarcerated or engaged with Justice

Currently in a Mental Health Unit or Mental Health Inpatient

Unsafe home environment

Homelessness or Between homes

29. Please enter any information relevant to the participants current living situation below:

30. Does this participant engage in any of the following risky behaviours:

Substance Misuse

Alcohol use

Smoking

Marijuana Use

Poly Substance Use

Unsafe Sex

Use of Prostitution

Fire starting behaviour

Sexual behaviours or concerns

Eating Disorder: Please specify in next question

Previous Eating Disorder: Please specify in next question

Self Harm Behaviours

Suicide Ideation

Previous self harm or life taking attempt

Family history of Substance Abuse

Family history of Mental Illness

Family history of criminality

31. Please enter any information relevant to the participant behaviours of risk: