SelfReferral - Interacting Minds

Interacting Minds Referral Form

Welcome to Interacting Minds. Before you begin, please send a copy of your participants NDIS plan and any relevant documents to support@interactingminds.com.au

Please enter the following details.

1. What is your name?

2. What is your Date of birth?

3. What is your home address

4. What is your type of accommodation?

Private

Supported Accommodation

Aged Care

Mental Health Facility

NDIS Plan Details

5. NDIS Number

6. Start Date of plan

7. Date of plan review

8. End Date of plan

9. Please select type of funding:

Self Managed

Plan Manager

NDIA Managed

Mainstream Cost Agreement

Plan Manager Details:

10. Do you have a nominee or are you your own decision maker?

Yes

11. Nominee Name:

12. What is the nominees relationship to you?

13. Nominee email address:

14. Nominee phone number:

15. Is the key carer the nominee?

Yes

Other

16. Do you attend day program, or school, please provide the information:

17. If you do attend any of these programs, what professionals are involved?

18. Details of health professional involved:

Why are you making the referral?

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

More Details about yourself

Please enter the following.

20. What are your 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

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

22. 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

23. Please enter any information relevant to you current living situation below:

24. Do you engage in any of the following risky behaviours: Please tick

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

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

Submit

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