Referrals

Do you or someone you know need support?

Complete the below referral form and we will make contact to discuss your needs.

If you are unsure about what services you need or if Activated Concepts is the right fit, please contact us via a general enquiry on the 'Contact Us' page to discuss your specific questions or Call us: (02) 4023 3122

Which of our services would you like? *

Disability Services
Mental Health Services
Child and Family Services
Ageing and Homecare Services
Clinical Training and/or Masterclasses
Other Services

Participant's Legal Name *

First

Middle

Last

Date of Birth *

Day/Month/Year

Gender *

Learner and/or Organisation Contact Name

Participant / Organisational Contact Name

Best Contact Number(s) *

Address *

Address Line 1

City

State / Province / Region

Postal Code

Email *

Does the Participant identify as being Aboriginal or Torres Strait Islander *

Aboriginal
Torres Strait Islander
No - not Aboriginal or Torres Strait Islander
I am not sure or prefer not to say

Does the Learner identify as being Aboriginal or Torres Strait Islander *

Aboriginal
Torres Strait Islander
No - not Aboriginal or Torres Strait Islander
I am not sure or prefer not to say

Does the Participant identify as being Culturally and Linguistically Diverse (CALD) *

Yes
No
I am not sure or prefer not to say

Does the Learner identify as being Culturally and Linguistically Diverse (CALD) *

Yes
No
I am not sure or prefer not to say

Is an Interpreter Required *

Language Spoken at Home *

Is the Participant under 18 years old or do they have a Guardian or Carer? *

Parent/Guardian/Carer

Name *

First

Last

Relationship to Participant *

Best Contact Number(s) *

Email *

Disability Service(s) Requested *

NDIS Improved Relationships/Behavioural Support
NDIS Daily Living Supports
NDIS Community Access Supports
NDIS Allied Health and Assessments
NDIS Short Term Accommodation (Respite)
NDIS Medium Term Accommodation
NDIS Individualised Living Options (ILO)
NDIS Semi-Independent Living (SIL)
Other NDIS/Private Services

Mental Health Service(s) Requested *

Mental Health Services (Private)
Mental Health Services (Victims of Crime)
Mental Health Services - Certificate of Injury
Mental Health Services (Insurance)
Mental Health Services (DVA)
Mental Health Services - Assessments

Ageing and Homecare Service(s) Requested *

Commonwealth Home Support Programme (CHSP) Support
Home Care Package (HCP) Support
Allied Health and Assessments
Private Supports
Other

Child and Family Support Service(s) Requested *

PSP Positive Behaviour Support
Therapeutic Supports and Assessments
General Support Work
Family Group Conferencing
Foster Care / Carer Assessments
Other Family Support Services

Training Service(s) Requested *

Organisational Training
One-on-One Training
Group Training
Other

Other Service(s) Requested *

Allied Health and Assessments
Student Placements
Clinical Supervision
WDO Applications
Other

Goals and Needs

Please describe any specific NDIS goals you would like to achieve with Activated Concepts? *

Please describe any specific goals you would like to achieve with Activated Concepts? *

Please describe the preferred days, hours and times for your supports *

Please describe any support needs (i.e. access, any preferences regarding the worker etc) *

Background Information & Risk Assessment

Any diagnosed, or suspected, psychological and/or physical information we should be aware of? *

i.e. Attention Deficit Hyperactivity Disorder, Austim, Bipolar, Borderline Personality Disorder, Learning & Developmental Disabilities, Traumatic Brain Injury (TBI) and Post-Traumatic Stress Disorder (PTSD), Schizophrenia, Visual etc

Other agencies/supports involved:

Please provide: Name, role, contact number and/or email.

To assist us with intake, can you inform of the primary approval reason: *

Adult Sexual Abuse
Adult Assault / Abuse (Family and domestic violence, unlawful assault, and assault etc)
Childhood Sexual Abuse
Childhood Assault / Abuse (Family and domestic violence, unlawful assault, and assault etc)
Home Invasion / Robbery
Homicide, including manslaughter and murder
Secondary Victim
Other

To assist us with intake, do any of the following apply to you: *

I have seen another Victims of Crime Clinician and used some of my hours
I have used one (1) of my 'no show' allowance.
I have used all my 'no show' allowance.
I have multiple approved claims / have experienced multiple acts of violence in NSW
I want assistance applying for new claims and/or recognition payments
None of the above apply to me.

Please note: A 'no show' is a late cancellation and/or no show to a session. Victim Services NSW only allows two of these before they do not pay clinicians.

To help us with intake, please indicate if you are seeking support with any of the following areas or if any of these factors apply: *

Currently experiencing family and/or domestic violence, including cohabitation with the offender
Currently experiencing family and/or domestic violence, without cohabitation with the offender
Current alcohol and/or other substance misuse within the past three months
Past history of alcohol and/or substance misuse
Recent self-harm (e.g., cutting, risk-taking behaviors) within the past three months
Past history of self-harm (e.g., cutting, risk-taking behaviors)
Recent thoughts of suicide within the past three months
Past history of suicidal thoughts
Presently experiencing homelessness or residing in transitional housing
None of these factors are applicable

To assist us with intake, can you inform of any current legal matters that apply: *

Family Court
Child Protection
Guardianship
AVO, DVO or other legal matters
Other
I do not have any current legal matters

Please provide more information around the legal matters: *

Order and/or court dates, support needed etc

Are there any other risk(s) we should be aware of? *

Behavioural incidents, lapses in AOD (Alcohol and Other Drugs) management, and contact from unauthorised parties, etc.

Please detail any behavioural, substance or other concerns below. *

If you have a risk assessment that can be provided please attached this at the end of the referral and you do not need to complete this section to save time.

When was the last incident *

Are there any evidenced strategies that reduce risk?

If there is a Positive Behaviour Support Plan (PBSP) or any other supporting documents, please attach these at the end of this referral.

Payment Details

Payment Method *

Self Funded (Private)
Victims of Crime

Plan Options *

Standard Therapeutic Session - $190.00
Therapeutic Session Pack - Four Sessions - $680.00
Therapeutic Session Pack - Six Sessions - $900.00
I'd like to chat further about my needs - $0.00

Medicare/Insurance rebated session(s) can only be paid for individually. Therapeutic supports are based on a person-centered approach, whilst applying Focused Psychological Strategies to support individual wellbeing goals.

Reference Number *

Approved Hours *

Payment Method *

NDIS Self-Managed
NDIS Portal
NDIS Plan Managed

NDIS Funding Available / Allocated for this Referral *

Please be as specific as possible to assist with intake, planning and the development of the schedule of supports.

NDIS Number *

Is the NDIS Plan on PACE?

Yes
No
Unsure

This is noted on the NDIS Plan itself and important for us to know to support timely supports being engaged. If unsure, we can call you to discuss.

NDIS Plan Start Date *

NDIS Plan End Date *

NDIS Plan Manager

Name *

Is there an Account Manager/Key Contact in the agency for the Participant? *

Payment Method *

Commonwealth Funding
Home Care Package
Private
Other

Payment Method *

Self Funded (Private)
Government Funding
Organisational Funding
Other

Referrer Details

Is this referral on behalf of the Participant? *

Name *

Relationship to Participant *

Best Contact Number(s) *

Email *

Has the Participant given consent for their data to be collected for the purpose of making a referral and providing appropriate support?

Yes
No
Unsure

Who should be initially contacted to follow up this referral and arrange services?

Myself, I will liaise with the Participant to confirm supports
The Participant is the best person to confirm supports
The Representative noted in Parent/Guardian/Carer section

PLEASE NOTE: Our administrative team are likely to be the first point of contact to confirm referral information and book initial meetings with service delivery staff.

Other Information

How did you hear about us? *

Activated Concepts / Clinical College Websites
General Word of Mouth
Activated Staff
Participant / Family Referral
Facebook / Social Media
Google / General Search
Government Department
Other Community Organisation
Other

Please specify *

Please name the source to support us with understanding our community needs. i.e. DCS, DCJ, Hunter Women's Centre, East Lakes, NOVA, Matthew Talbot, Life Without Barriers, Hunter Primary Care etc

Send confirmation email to:

Is there any further information you would like us to be aware of?

People that have consent, alternate contact numbers, other matters that are not covered in this referral form etc.

Please add any relevant attachments to your referral

Click or drag files to this area to upload.You can upload up to 15 files.

NDIS Plan, PBS Plans, Psychological Reports, Victims of Crime Approval Letter, Case Plans, Care Plans, Allied Health Assessments, Risk Assessments etc

Referrals

Do you or someone you know need support?

Complete the below referral form and we will make contact to discuss your needs.

If you are unsure about what services you need or if Activated Concepts is the right fit, please contact us via a general enquiry on the 'Contact Us' page to discuss your specific questions or Call us: (02) 4023 3122

Parent/Guardian/Carer

Goals and Needs

Background Information & Risk Assessment

Payment Details

NDIS Plan Manager

Referrer Details

Other Information

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