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Referral
Contact
1300 020 271
Refer yourself, a dependent or a client for the care they deserve
I am referring
*
Select
Myself
Child / Dependent / Loved One
Client
Funding Source
*
Select
National Disability Insurance Scheme (NDIS)
Medicare / Mental Health Plan
Private Health Insurance
Fee for Service
How did you hear about us?
*
Select
Word of Mouth
Social Media
Advertisement
Google Search
Other
Name (First & Last)
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Phone Number
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Email Address
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Health Insurance Provider
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Health insurance Provider ABN
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Membership Card Number
*
IRN Number
*
Customer Reference Number (If Applicable)
Policy Start Date
*
Name (First & Last)
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Phone Number
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Email Address
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Date of Birth
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Street Address
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Suburb
State
Postcode
Living Arrangements
*
Select
Lives Alone (Owner, Renter, Other)
Lives with Family
Group Home
Department of Housing
Aged Care Facility
Incarcerated
SIL Housing
SDA Housing
Cultural Background
*
Select
Australian
Aboriginal
Torres Strait Islander
Other
Primary Disability Group
*
Select
Acquired Brain Injury (ABI)
Autism Spectrum Disorder (ASD)
Hearing
Speech
Vision
Physical
Neurological
Psychological
Psychiatric
Intellectual Disability (ID)
Difficulty Swallowing / Eating / Drinking
Communication
*
Select
Verbal
Non-Verbal
Interpreter Required
Hearing
*
Select
No Impairment
Impairment
Hearing Device
Deaf
Vision
*
Select
No Impairment
Impairment
Blind
Mobility
*
Select
No Impairment
Under 3 Years
With aids
Wheelchair Independent
Wheelchair Assisted
Are there any behaviors of concern to be aware of?
*
Select
Verbal aggression / threats
Physical aggression / threats
Property damage / destruction
Wandering / Absconding
Food Related (binging / refusal)
Self-harming behaviour
Suicidal ideation / behaviour
Sexualised behaviours
Harm to Animals
Fire Lighting
Repetitive Behaviours / Fixations
Do you require a behaviour support plan?
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Yes - New Plan
Yes - Review Existing Plan
No
Do any restrictive practices apply?
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Seclusion
Mechanical
Environment
Physical
Chemical
No
I confirm all given information is accurate and consent to Butter Fish Services using it to arrange care and therapeutic services as stated in the privacy statement
*
Yes
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