Behavioural Therapy Referral Form

Once you have completed the form please email it back to admin@steps2lifecare or if you have any questions or
need support filling this form out, please call us on 02 9638 3362 .

Please allow for 3 business days for your referral
to be processed. 

    What best describes you?
    Please tick all of applicable boxes and provide details if applicable

    Do you have a particular Team Member that you would like to work with?

    Funding Information

    NDIS Plan Start Date

    NDIS Plan End Date

    How do I pay for my supports?

    You are allocating Create A Sense of Place the following amount of funding from your (choose one or several of the following options):

    Core- Assistance with Daily Life : Assessment, Recommendation, Therapy and/or Training (including Assistive Technology) - Psychology - 01_701_0128_1_3

    Core- Assistance with Daily Life : Other Therapy Assessment Recommendation Therapy And/or Training (Incl. AT) - Other Therapy 01_741_0128_1_3
    $193.99

    Improved Relationships Budget for Specialist Behavioural Intervention Support - Line Item: 11_022_0110_7_3

    Improved Relationships Budget for Behaviour Management Plan Incl. Training In Behaviour Management Strategies - Line Item: 11_023_0110_7_3 -

    Capacity Building Supports for Early Childhood Interventions - Psychology - Line Item: 15_001_0118_1_3

    Capacity Building Supports for Early Childhood Interventions - Other Therapy - Line Item: 15_005_0118_1_3

    Capacity Building Supports for people older than 7yrs for Assessment, Recommendation, Therapy or Training (including Assistive Technology) - Psychology
    - Line Item: 15_054_0128_1_3

    Capacity Building Supports for people older than 7 yrs for Assessment, Recommendation, Therapy or Training (including Assistive Technology) - Other Therapy
    - Line Item: 15_056_0128_1_3

    Participant Details

    Is there a Plan Nominee?

    Is there a current Behaviour Support Plan in place?

    Are there currently any restrictive practices in place?

    Is there anything that we should be made aware of?
    This may include best methods of communication, any safety concerns, guardianship, etc.

    Are there any other supporting documentation that you would like to attach
    (assessments/specialist letters etc)

    Who is the best person/s to contact regarding this referral?