1 Step 1 Healthy Minds NDIS Referral Form NDIS Referral Details NDIS Line Item / CategoryHealthy Minds charges at the standard NDIS rate per hourImproved Daily Living (Assessment, Recommendation, Therapy And / Or Training Psychology / Accredited Mental Health Social Worker)Improved Daily Living (Psychological Functional Assessment)Improved Relationships (Specialist Behaviour Support Intervention) Recommended 12 hours Hours Specialist Behavioural Intervention Support Hours Behaviour Management Plan and Training in behaviour Management Strategies Hours Assessment, Recommendation, Therapy And / Or Training Psychology / Accredited Mental Health Social Worker Hours Psychological Functional Assessment Plan Start Datedate_range Plan End Datedate_range Preferred Delivery MethodIn OfficeOut of OfficeTelehealth Out of office consultations are available in the following areas:Melbourne: Darebin, Moreland, Hume, Moonee Valley, Maribyrnong, Brimbank, Wyndham, Hobson Bay, Melton Shire, Macedon Ranges Shire, Whittlesea How is the Plan Managed?Self-ManagedPlan ManagedNDIA Managed Please inform the plan manager about this referral Please provide the Agency name and contact Please provide contact details Agency Name Agency Phone Agency Fax Agency Emailemail Contact Name Contact Phone Contact Fax Contact Emailemail Is there a support coordinator?If yes, please provide detailsYesNo Support Coordinator's Details Coordinator Name Coordinator Agency Coordinator Phone Coordinator Emailemail Referral Datedate_range Is the support coordinator also the referrer?YesNo Referring Provider's Details Referrer Name Referrer Agency Referrer Phone Referrer Emailemail Participant Details NDIS Number Participant Name Preferred Name GenderFemaleMalePrefer not to sayNon-binary Address Living ArrangementAloneFamily / PartnerSupported AccommodationOther Date of Birthdate_range Phone number Participant Emailemail Does the participant have impairment/s that affect their receptive or expressive communication?YesNo Level of Communication Are communication aids required?YesNo How does the participant communicate their needs and wants to supports and family?Tick all that applyUses verbal language / speech (and gestures)Uses gestures to communicateUses eyes / gaze onlyUse of personal communication board/book or iPad / electronic communication toolOther (please provide details) Communication - details0 / Guardian / Parent Details Is the participant under the care of a guardian or parent OR is the participant under 16 years of age?If yes, please provide detailsYesNo Guardian / Parent 1 Guardian / Parent 2 Name 1 Name 2 Relationship / Organisation 1 Relationship / Organisation 2 Address 1 Address 2 Phone 1 Phone 2 Email 1email Email 2email Who is the primary contact for an appointment?ParticipantFamily MemberSupport CoordinatorOther Primary contact for appointments Alternate Contact (in case the NDIS participant or Support Co-ordinator is unreachable) Alternate Contact Name Alternate Contact Relationship Alternate Contact Emailemail Alternate Contact Phone Are there any court orders or custody arrangements / family disputes that Healthy Minds needs to be aware of?If Yes, please provide detailsYesNo Court Orders / Custody Arrangements Details0 / Are there any restrictive practices in place?If Yes, please provide detailsYesNo Restrictive Practices Details0 / Safety Is anyone at your/the participant's property known to be aggressive or violent?YesNo Aggression or violence - details0 / Does anyone at your/the participant's property have a criminal history?YesNo Criminal history - details0 / Does the participant currently have a positive behavioural support plan in place?YesNo If yes, please upload a copy of the PBS at the bottom of this form. Is there a history of drugs or alcohol misuse at the property?YesNo Drugs or alcohol misuse - details0 / Are you aware of any firearms being stored at the property?YesNo Firearms - details0 / Are you aware of any occupant having an infectious disease?(i.e. chicken pox, COVID-19, gastro etc.)YesNo Infectious diseases - details0 / Are there any pets at the premises?YesNo Pets - details0 / Are there any other physical or environmental concerns that the practitioner should be aware of?If Yes, please provide detailsYesNo Physical or environmental concerns - details0 / Referral Details Reason for Referral0 / Relevant information: including diagnosis / main disability0 / Identified goals / desired outcomes of the Therapy or Behavior Support as stated in NDIS plan0 / Are there other Health Professionals involved that you would like Healthy Minds to work with?If yes, please provide detailsYesNo Contact Name 1 Field / Occupation 1 Organisation 1 Contact Number 1 Contact Name 2 Field / Occupation 2 Organisation 2 Contact Number 2 Contact Name 3 Field / Occupation 3 Organisation 3 Contact Number 3 Please upload a copy of the participant's NDIS Public Plan5MB maximumcloud_uploadUpload Please upload any other relevant reports5MB maximumcloud_uploadUpload If your document fails to upload, please email to:info @ healthyminds.net.au Submit Form keyboard_arrow_leftPrevious Nextkeyboard_arrow_right
