Inter Health Services Referral Form Inter Health Services Referral Form Client Details ▶ Full Name: Date of Birth: Home Phone: Mobile Phone: Email: Street Address: Postal Address: NDIS No: Plan Expiry Date: Medicare No: Expiry Date: Work Contact: Emergency Contact ▶ Full Name: Relationship: Phone: Address: Plan Management & Support Details ▶ Plan Manager Name: Contact: Support Coordinator Name: Email: Organisation: Funding Type: Self-Managed Plan Managed NDIA-Managed Privately Funded Plan Duration: Funding Allocations (if known): Core Supports: $ Capacity Building: $ Improved Daily Living: $ Behaviour Support: $ Referral Purpose / Client Risk & Needs Assessment ▶ Referral Purpose Therapy & Counseling Services Individual Counselling (CBT, Trauma-Informed, DBT) Group Counselling (CBT, Trauma-Informed, DBT) Emotional Regulation & Wellbeing Support Carer & Family Psychoeducation Assessments Functional Capacity Assessment (FCA) Psychosocial Assessment & Intervention NDIS Review Reports & Recommendations Positive Behaviour Support (PBS) Plan Development Restrictive Practice Consultation 🔗 Brave Connections PBS Referral Form: https://brave-connections.splose.com/public-form/2f5b6d8b-bf85-464d-8f38-2d389bab1598 Professional Development Clinical Supervision for Mental Health & Social Work Trauma-Informed Training Sessions Cultural Competency & CALD Practice Workshops Professional Development for Practitioners Client Risk & Needs Assessment Risk Level: No Known Risks Low Medium High Specific Concerns (Tick as needed): Self-Harm Harm to Others Aggression (Verbal/Physical) Wandering Hoarding Social Withdrawal Mental Health Decline Refusal of Care Attachments & Declaration ▶ Attachments Attach Additional Documents (if applicable): Specialist Reports PBS Plan NDIS Review Reports Other: Please attach relevant documents such as Specialist Reports, PBS Plans, and NDIS Review Reports to help us process this referral efficiently. Upload a File: Accepted: PDF, DOCX, JPG, PNG Client/Guardian Declaration I consent to my information being provided to Inter Health Services for referral, service delivery, and inclusion in de-identified data reporting. Full Name: Date: Signature of Client/Guardian: By typing your name and submitting this form, you acknowledge that you have read and agree to the terms and conditions outlined above. 📩 Submit Form Email: information@interhealthservices.com.au | Website: https://www.interhealthservices.com.au
