Referral Registration Form – Sunrise Behavioural Health Referral Registration Form

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; and
Consent*
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 details
Title
Name of referrer*
Organisation/person making the referral*
Date of referral*

DD
MM
YYYY
Telephone*
Email address
Street address*
Street address line 2
Suburb*
State
Postcode*
Preferred name
Referral type*
- NDIS package
- Territory Families
- Corrections
- Individual Support Package (ISP)
- MACNI
- Futures 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 details
Given name*
Surname*
Preferred name*
Gender*
- Male
- Female
Date of birth*

DD
MM
YYYY
Address*
Telephone*
Email*
Communication aides
Person consents to share information
Person consents to contact
Preferred method of contact
NDIS Funding Start Date*

DD
MM
YYYY
NDIS Funding End Date*

DD
MM
YYYY
NDIS participant number*
Is the funding NDIA managed?
Is the funding Plan Managed?
Is plan-managed, please provide details?
Name of the company managing plan*
Email*
Phone
Is the funding self-managed?
Amount of funded service (Behaviour, ECEI)

Carer’s / parents/ guardians details
Given name*
Surname*
Preferred name
Gender*
- Male
- Female
Address*
Telephone
Email
Preferred method of contact
Preferred time to contact
Reason for referral
Brief 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/interventions
i.e., - Functional Behaviour Assessment (FBA) -Development of Behaviour Support Plan (BSP) - Training carers / staff & direct implementation of BSP

Cultural considerations
Spiritual and/or Cultural requirements
Spiritual belief or Religion
Aboriginal or Torres Strait Islander
If answering yes; What is the person’s clan?
Language group
Cultural mentor
Their connection with their land/community
English proficiency. Spoken and written
Need for an interpreter? If so, language type

Health, mental health, disability and/or substance use
Mental health
Depression, anxiety, eating or psychotic disorder
Neurodevelopment Disorders
Autism, ADHD, dyslexia
Cognitive impairment
Intellectual disability, ABI
Physical health, medical issues
Any issues relating to physical/medical
Substance 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

Form

Step 1 of 6

Referrer details

Participant details

Carer’s / parents/ guardians details

Cultural considerations

Health, mental health, disability and/or substance use