PBS Intake Referral

Detailed referral assessment for Positive Behaviour Support. All fields marked with * are required.

First Name *

Last Name *

Date of Birth *

Gender

NDIS Number *

Home Address

Suburb *

Living Arrangement

Primary Language

Full Name *

Relationship *

3. Reason for Referral

Describe the behaviours of concern. Include frequency, intensity, duration, and known triggers. * How do these behaviours impact daily life? What strategies have been tried? What worked and what did not?

4. Medical History

Primary Diagnosis *

Secondary Diagnoses

Co-occurring Mental Health Conditions: Anxiety Depression PTSD Bipolar Schizophrenia Other

Current Medications (Name, Dose, Frequency): Allergies:

5. Communication

Describe the participant's communication style (verbal, non-verbal, AAC devices, signs): Ability to understand verbal instructions: Sensory sensitivities or processing differences:

6. Current Supports

Support Coordinator Name

SC Organisation

Current NDIS Funded Supports: Support Coordination Core Supports Community Access Occupational Therapy Speech Pathology Psychology SIL / Accommodation Other

Has the participant received PBS before?

Are Regulated Restrictive Practices used? *

7. Risk & Safety

Check all risks that present safety concerns: Self-harm Suicidal thoughts / attempts Physical aggression Verbal threats / abuse Property damage Absconding Inappropriate sexualised behaviour Substance misuse

Is there an active Safety Plan or Behaviour Support Plan? Additional Risk/Safety details:

8. Goals

What does the participant want to achieve? * What does the family / support network hope to achieve from PBS? Describe what a "good life" would look like for this participant:

9. Urgency & Availability

Level of Urgency *

Location Preference *

Preferred Days: Monday Tuesday Wednesday Thursday Friday

10. Marketing Intake

How did you hear about our service/s? * Tell us more (e.g. name of coordinator, name of expo):

11. Consent & Submit

By completing this referral, you confirm that you have permission to share this personal data with the Facilitatrix clinical team.

I consent to Facilitatrix collecting and storing this data. * I consent to Facilitatrix communicating with other providers (e.g. Support Coordinator, GP).

Once submitted, a Behaviour Support Practitioner will review the intake data and contact the referrer within our target triage response timeline.