Registration / Referral Form Form Step 1 of 6 16% We are committed to protecting your privacy and know it is important for you to understand how your information is handled.In submitting the information contained in this form, you:* Acknowledge that your support practitioner/clinician and Sunrise Behavioural Health will collect such information (including any personal or sensitive information), for the purposes of providing you with allied health/ disability support services, or similar other services or enabling any related communications; andConsent* Consent to Sunrise Behavioural Health's Terms & Conditions , and to Sunrise Behavioural Health Pty Ltd handling your personal and sensitive information in accordance with its Privacy Policy.* Referrer detailsTitle--Select One--MissMsMrsMrDrOtherName of referrer*Organisation/person making the referral*Date of referral* DD MM YYYY Telephone*Email address Street address*Street address line 2Suburb*StateNSWACTVICTASQLDWASANTPostcode*Preferred nameReferral type*NDIS packageTerritory FamiliesCorrectionsIndividual Support Package (ISP)MACNIFutures for Young Adults (FFYA)Targeted Care Packages (TCP)Transport Accident Commission (TAC)Reason for referral*Behavioural concerns, adaptive skills, language & communication, social skills, brain injury, transition, aggression, self-management etc.Current Situation*Eg, behaviours of concern, relationship issues, transition, adjustment issues etc.Current supports in place*GP, psychologist, informal supports, disability support, Support Recommendations*Counseling, social work, specialist behaviour support, applied behaviour analysis Participant detailsGiven name*Surname*Preferred name*Gender*MaleFemaleDate of birth* DD MM YYYY Address*Telephone*Email* Communication aides--Select One--YesNoPerson consents to share information--Select one--YesNoPerson consents to contact--Select one--YesNoPreferred method of contact--Select one--PhoneEmailSMSIn WritingFace of faceUnkownNDIS Funding Start Date* DD MM YYYY NDIS Funding End Date* DD MM YYYY NDIS participant number*Is the funding NDIA managed?--Select one--YesNoIs the funding Plan Managed?--Select one--YesNoIs plan-managed, please provide details?--Select one--YesNoName of the company managing plan*Email*PhoneIs the funding self-managed?--Select one--YesNoAmount of funded service (Behaviour, ECEI) Carer’s / parents/ guardians detailsGiven name*Surname*Preferred nameGender*MaleFemaleAddress*TelephoneEmail Preferred method of contactPhoneEmailSMSIn WritingFace of faceUnkownPreferred time to contactReason for referralBrief description of the reason for referral. i.e., behavioural support needs, deficits in adaptive behaviours, social skills, self-management, language & communication, activities of daily living etc.Anticipated number of sessions/interventionsi.e., - Functional Behaviour Assessment (FBA) -Development of Behaviour Support Plan (BSP) - Training carers / staff & direct implementation of BSP Cultural considerationsSpiritual and/or Cultural requirements--Select one--YesNoUnknownSpiritual belief or ReligionAboriginal or Torres Strait Islander--Select one--YesNoIf answering yes; What is the person’s clan?Language groupCultural mentorTheir connection with their land/communityEnglish proficiency. Spoken and writtenNeed for an interpreter? If so, language type Health, mental health, disability and/or substance useMental healthDepression, anxiety, eating or psychotic disorderNeurodevelopment DisordersAutism, ADHD, dyslexiaCognitive impairmentIntellectual disability, ABIPhysical health, medical issuesAny issues relating to physical/medicalSubstance use (current)Illegal or prescribed Any other information (court orders, guardianship, current living arrangement etc)Anything else you believe will assist in building a better understanding of the persons needs. Include behaviors of concern, previous supports Our practice will work closely with other agencies to coordinate the best support for you. This means your informed consent for the sharing of information will be sought and respected in all situations unless: we are obliged by law to disclose your information regardless of consent or otherwise. it is unreasonable or impracticable to gain consent or consent has been refused; and the disclosure is reasonably necessary to prevent or lessen a serious threat to the life, health or safety of a person or group of people. Do you agree to the terms & conditions?* I hereby acknowledge that I am aware of my right to access my personal information.* I hereby acknowledge that I am aware of my right to withdraw my consent at any time.** I understand that my provider must comply with relevant privacy laws and I will contact the organisation immediately if I feel that these laws have been beached.** I understand why certain information about me may need to be provided to other service providers in order to coordinate the best support for me.*Signature*Date* DD MM YYYY