Make a Referral — Beneath the Behaviour

In an emergency, call 000. For urgent mental health support, Lifeline is available 24/7 on 13 11 14.

Don't fill this out if you're human:

About you

The person making this referral.

Full name *

Relationship to the person *

Phone *

Email *

Organisation (if applicable)

About the participant

Full name *

Date of birth *

NDIS number (if known)

Best contact number

Address (suburb is fine if you're not sure of the full address)

Does the participant have a guardian or authorised decision-maker?

Yes No Not sure

Guardian / decision-maker name & contact (if applicable)

NDIS plan details

How is the plan managed? *

Self-managed Plan-managed NDIA-managed Not sure

Is there funding for behaviour support (Improved Relationships) in the current plan?

Yes No Not sure

How much Improved Relationships funding is available?

When does the NDIS plan expire?

What's going on

This helps us understand what support might look like — there's no need to have all the answers yet.

What behaviours or challenges prompted this referral? *

How long has this been happening?

What other supports or services are currently involved?

Are any restrictive practices currently being used?

SeclusionE.g., locking or leaving someone alone in a room or area they can't leave Chemical restraintMedication used to control behaviour, rather than to treat a diagnosed condition Mechanical restraintE.g. gloves/mittens or a helmet to prevent someone self injuring or injuring others Physical restraintHolding or physically restricting someone's movement Environmental restraintRestricting access to things or spaces, e.g. locking the fridge or a kitchen None currently in use I don't know

Anything else we should know?

Consent

We'll be in touch within a couple of business days.

Questions before you refer? Reach out directly and we're happy to talk it through first.