Melbourne offices: (03) 9330 0759 Yeppoon office: (07) 49 284 771

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Healthy Minds NDIS Referral Form
NDIS Referral Details
NDIS Line Item / CategoryHealthy Minds charges at the standard NDIS rate per hour

Recommended 12 hours

Specialist Behavioural Intervention Support

Behaviour Management Plan and Training in behaviour Management Strategies

Assessment, Recommendation, Therapy And / Or Training Psychology / Accredited Mental Health Social Worker

Psychological Functional Assessment

Preferred Delivery Method

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

Rockhampton (including Capricorn Coast)

Preferred Office Location
How is the Plan Managed?

Please inform the plan manager about this referral

Please provide the Agency name and contact
Please provide contact details
Is there a support coordinator?If yes, please provide details
Support Coordinator's Details
Is the support coordinator also the referrer?
Referring Provider's Details
Participant Details
Living Arrangement
Does the participant have impairment/s that affect their receptive or expressive communication?
Are communication aids required?
How does the participant communicate their needs and wants to supports and family?Tick all that apply
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 details
Guardian / Parent 1
Guardian / Parent 2
Who is the primary contact for an appointment?
Alternate Contact
(in case the NDIS participant or Support Co-ordinator is unreachable)
Are there any court orders or custody arrangements / family disputes that Healthy Minds needs to be aware of?If Yes, please provide details
Are there any restrictive practices in place?If Yes, please provide details
Is anyone at your/the participant's property known to be aggressive or violent?
Does anyone at your/the participant's property have a criminal history?
Does the participant currently have a positive behavioural support plan in place?

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?
Are you aware of any firearms being stored at the property?
Are you aware of any occupant having an infectious disease?(i.e. chicken pox, COVID-19, gastro etc.)
Are there any pets at the premises?
Are there any other physical or environmental concerns that the practitioner should be aware of?If Yes, please provide details
Referral Details
Are there other Health Professionals involved that you would like Healthy Minds to work with?If yes, please provide details

If your document fails to upload, please email to:

ndis @