Hello & Welcome

First Name (Legal) *

Last Name *

Date of Birth *

Preferred Name *

Pronouns (She/He/They/Ze) *

Where are you located?

Brisbane (QLD)Sydney (NSW)Melbourne (VIC)Other

Do you identify as?

Gay Lesbian BisexualPansexualNon-Binary Transgender Gender Diverse (Other)Queer Other

Do You Identify As First Nations? *

Phone Number *

Email Address

Street Address *

City *

State *

Postcode *

Client Representative Details (If Applicable)

First Name

Last Name

Phone Number

Street Address

City

State

Postcode

NDIS Details

Payment method *

Plan Managed Self Managed Agency ManagedPrivateMental Health Care Plan (MHCP)

Plan Manager Name (If Applicable)

Plan Manager Agency (If Applicable)

NDIS Number

Plan Start Date

Plan Review Date

Referrer Details (Person Making the Referral)

First Name

Last Name

Agency

Role

Email Address

Phone Number

I have obtained consent from the participant/individual to make this referral and provide Rainbow Mindset with the participant's/individual's personal and medical details. *

Reason For Referral

Referred For *

Functional Capacity Assessment (FCA)Positive Behaviour Support Planning (PBSP)Social Work Counselling & PsychotherapyCommunity NursingOther

Current psychosocial experience *

Medication *

Times & Days For Support (Approximate) *

Restrictive Practice? (Legally binding) *

Yes No

File Upload (Please attach a copy of the current NDIS plan if applicable))

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Risk Assessment Private & Confidential

Are there any safety concerns we need to be aware of? *

Any occupants, visitors, pets that may pose a threat? *

Does anyone have a history of violence: physical, sexual, verbal aggression? *

Any substance abuse issues? *

Any AVO’s, criminal offences - anyone who may have an issue with the clinician visiting home? *

Any known weapons or firearms? *

Are any medications, controlled substances or drugs administered intravenous *

Do you or someone in your home carry airborne, contact or blood borne diseases? Example: (Tuberculosis, Polio, HIV, Hepatitis, HSV, MRSA?)

I understand that Rainbow Inclusions staff require a safe working environment. I have answered the Rainbow Inclusions risk assessment questions truthfully and/or to the best of my ability/knowledge. *

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