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About Us
Meet the team
Cronulla
Wollongong
Dapto
Woonona
Shellharbour
Our services
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FAQ
Should I see a psychologist?
Refer To Us
NDIS Referrals
Contact
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Plan Manager Details
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Client Details
Name
*
First
Last
Phone
*
Date of Birth (DD/MM/YYYY)
*
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NDIS Screening
1. You are the client's:
Parent
Guardian
Carer
Support Worker
Your Name
First
Last
Your Phone Number
Email
2. Has the client's permission been obtained to make this referral?
*
3. What is the client's diagnosis and severity of their condition?
4. Has the client been previously treated for this condition by a psychiatrist/psychologist?
Yes
No
5. If answered yes to question 4, what was the duration, frequency and outcome of this treatment, if any?
6. Please list anyone else involved in the client's treatment (GP, psychiatrist, OT etc) If so, how often do they see them?
7. What are the specific goals that the client wishes to address in counselling sessions?
8. How comfortable is the participant in being outdoors and interacting in social settings?
9. How likely is the participant to stay with the clinician during the session?
10. Describe the client's communication skills:
11. Does the client engage in any violent behaviour (swearing, hitting etc) towards themselves or others, and if so, please describe:
12. Does the client have meltdowns and if so, please describe the nature and any known triggers for the client's meltdowns:
13. How frequent, if any, are the client's meltdowns?
Multiple times a day
Once a day
Few times a week
once every week/s
14. What support have the parents/guardians/carers sought to identify and manage any behavioural issues?
15. Please outline why you/the client has chosen an outdoor service over an indoor one?
Has there been any behavioural managed plans developed for the participant, and if so please upload here or bring to the first session:
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