Client name: Client's date of birth: Reason for referral: Available government funding source NDIS plan Home care package DS/HACC Continuity of Care funding (+65) None Does the client prefer to use FFS for this referral? Yes No Preferred outcome (if known) e.g. assessment, new wheelchair, transfer docs: Checklist completed by: Relationship to client: Service, location and client address (e.g. Support at home - Fig Tree Pocket, 17 Rosella St, Fig Tree Pocket): Who to contact to set appointments (key contact name): Relationship of key contact to client: Key contact details - phone: 1. Does the person harm others? Please selectNeverOccasionallyOften 2. Is the person physically aggressive towards others? Please selectNeverOccasionallyOften 3. Does the person harm themselves? Please selectNeverOccassionallyOften 4. Are there ever concerns for the safety of staff members, co-tenants, or members of the public due to the person's behaviour? Please selectNeverOccasionallyOften 5. Does the person cause property damage? Please selectNeverOccasionallyOften 6. Is the person verbally aggressive towards others? Please selectNeverOccasionallyOften 7. Is the person prescribed medication in order to control their behaviour? i.e. given something to "relax" them? Please selectNeverOccasionallyOften 8. Do staff need to remove themselves to another location, at any time, because of the person's behaviour? Please selectYesNo 9. Does the person have any behaviours of concern that require additional staff at any time? Please selectYesNo 10. If yes, does the person's behaviour of concern ever require additional resources or equipment? Please name resource if used. Please selectYesNoN/A 11. Has a Riskman/incident report/s been completed for this person because of challenging behaviour? Please selectYesNo 12. Does the person currently have a Positive Behaviour Support Plan? Please selectYesNo 13. Does the person currently have *approved restrictive practices? Please selectYesNo Please summarise the person's behaviour/issues: Submit form Leave this field blank