Date of Referral *

Is this a Self-Referral *

Are you referring someone else for behaviour support, assessment and/or therapy services? *

Person Making Referral *

Person Making Referral Phone Number *

Person Making Referral Email Address *

Consent

Do you consent for the Rosewood Centre to work with you and support you? *

Unfortunately we are unable to provide help and support until you provide Verbal Consent to the Rosewood Centre.

Do you have verbal consent to share information about this person with the Rosewood Centre? *

If NO, please seek Verbal Consent from the participant or appropriate substitute decision maker prior to making this referral. Thankyou.

Is the participant able to give informed consent? *

If NO, who is the person who provides consent? *

Name of Person Giving Consent Contact Phone Number *

Name of Person giving Consent Email Address

Relationship of Person Giving Consent to Participant *

Participant's First Name *

Participant's Last Name *

Participant's Date of Birth *

ChildStory Number (if applicable)

Participant's Gender

Participant's Phone Number

Participant's Preferred Method of Contact

Your First Name *

Your Last Name *

Your Date of Birth *

Your Gender *

Participants Residential Address

Participant's Email Address *

Preferred Method of Contact *

What is your relationship with the participant? *

Is this referral funded under the NDIS? *

Is this an internal or external referral?Internal referrals are programs directly connected to the Rosewood Centre. External referrals are all 'other' agencies referring for Rosewood Centre services.

If INTERNAL, which program is this referral from?

If EXTERNAL, what agency is submitting this referral?

If Other, please identify the program

What services do you require?

If Other Assessment(s) is required, please list:

How will the Assessment be funded?

I confirm I have written approval from Casework Manager to proceed for a pre-approved funding for 6 sessions. *

How will Behaviour Support Services be funded?

How will Therapy Services be funded?

I confirm I have written approval from Casework Manager to proceed for a pre-approved funding for 6 sessions. *

Please identify, who will fund Out of Pocket Expenses?This is generally an Out of Pocket expenses associated with MHCP.

Preferred Service Locations

NDIS PLAN INFORMATION

It is really useful for us to understand your NDIS Plan. Some items may link to others and this is important as we can ensure you are getting the best options with your plan. Please share your NDIS Plan information. It will be strictly confidential and only assists us understand your needs.

Can you provide information about your NDIS Plan? *

Participant's NDIS Number *

NDIS Plan Start Date *

NDIS Plan End Date *

Category to claim from? *

If Improving Relationships, which Item Numbers are listed? *

If 11_022_0110_7_3 listed what is the amount? *Behaviour Assessment and Plan Development

Number of Hours

If 11_023_0110_7_3 listed, what is the amount? *Training, Coaching and Support

Number of Hours

How much Behavior Support funding is available? ($) *

Number of Hours

If Improved Daily Living, what services are required?

Therapy (Psychology)Assessment

If Assistance with Daily Life, what services are required?

Therapy (Psychology)Assessment

How much funding from your NDIS Plan is allocated for the selected Rosewood Centre Service? *

If possible, please upload a copy of your current NDIS Plan.

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Plan Management

How is your plan managed? *

Plan Management Provider Name? *

Plan Management Provider Email *

Reason(s) for Referral

What do you or the person you are referring need help with? *

Therapy Services

If 'Other', please provide further information

Behaviour Support Services

If OTHER, please describe what you need:

Behaviour(s) of Concern

Does this person engage in verbal and/or physical aggression? *

How often does this person engage in verbal and/or physical abuse *

Does this person engage in self harming behaviour? *

Does this person engage in behaviour that causes property damage? *

How often does this person engage in behaviours that cause property damage? *

Does this person engage in challenging sexualised behaviour? *

How often does this person engage in challenging sexualised behaviours? *

Does this person engage in challenging food based behaviour? *

How often does this person engage in challenging food based behaviours? *

Does this person engage in behaviour where they leave supervised settings? *

How often does this person engage in behaviours when they leave supervised settings? *

Does this person engage in behaviour where they are oppositional? *

Does this person engage in 'other' behaviours of concern? *

Please state this behaviour to enable a clear understanding.

How often does this person engage in 'other' as stated behaviours? *

Desired Outcomes

If other, please explain

Regulated Restrictive Practices

Regulated Retrictive Practices relate to certain practices that may impinge of a person's rights and capacity to make certain decisions. NDIS Registered Providers who utilise such practices to control behaviour need to undertake a range of additional actions to safeguard the persons rights. Families are generally NOT Registered providers although if NDIS providers are working in the family home AND implementing such practices they are considered to Restrictive and therefore regulated by the NDIS Quality and Safeguards Commission. Restrictive Practices are also regulated through the Office of the Children's Guardian and have similar requirements to how they are implemented and reviewed.

Are any Regulated Restrictive Practices used to control any of the identified behaviours of concern? *

Accessibility and Support

• Do you have additional needs around accessibility (e.g. require wheelchair access/unable to manage stairs).

A staff member will be in contact with you to plan the most suitable location for your appointment. Please continue completing the form.

Consultation and COVID 19 Restrictions

Due to Covid19 restrictions, The Rosewood Centre need to undertake a range of approaches when conducting consultations.

Please complete the information below to assist us in understanding what options are viable.

Preferred Days and Times for Consultation

Thank you for completing our online referral form. A member of our team will be in touch with you shortly with further information.

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