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How we help
- Our approach
- Resources
About
Work with us
- Vacancies
- Join us as an experienced PBS Practitioner
Make a referral
Get in touch
Search for:

How we help
- Our approach
- Resources
About
Work with us
- Vacancies
- Join us as an experienced PBS Practitioner
Make a referral
Get in touch
Search for:

Melior Referral FormElizabeth2024-07-03T17:01:49+08:00

Melior Referral Form

Please complete the Melior Referral Form as required.

If you require support to complete the form, please contact the Melior team on (08) 6325 4400.

Please click here to download the Melior Referral Form PDF.

Step 1 of 7

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Hidden Fields for Lumary

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Reason for Enquiry

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Source of Enquiry

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Requested Service

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Date(Required)

DD slash MM slash YYYY

I am referring...(Required)

Myself

Someone I know

Referrer Details

Your name(Required)

First Last

Organisation(Required)

Mobile Phone(Required)

Email(Required)

Relationship to client/participant(Required)

Select the most relevant option

Support coordinator

Partner

Parent

Family

Carer

Guardian

Other

Referrer preferred communication channel(Required)

Phone

Email

Client / Participant Details

Client's name(Required)

First Last

Gender(Required)

Male

Female

Non-binary

Prefer not to say

Other

Date of birth(Required)

DD slash MM slash YYYY

Phone number(Required)

Client email(Required)

Is the client contactable?(Required)

Yes

No

Unsure

Client preferred communication channel(Required)

Phone

Email

Do not contact

Client's address(Required)

Street Address Address Line 2 City ZIP / Postal Code

NDIS number(Required)

Hours of PBS funding in NDIS plan(Required)

Primary Disability(Required)

Details of disability(Required)

Primary contact details

Who is the primary contact?(Required)

Primary contact: Name(Required)

First Last

Primary contact: Mobile phone(Required)

Primary contact: Email(Required)

Primary contact: Preferred communication channel(Required)

Phone

Email

Do not contact

Primary contact: Relationship to client(Required)

Select the most relevant option

Partner

Parent

Family

Carer

Guardian

Other

Information to assist us to determine suitability & support needs

What are the three main areas of concern for the client?(Required)

Are there any risks that we should be aware of?(Required)

What is the client’s current living arrangements?

Place of residence

Will support be provided at the client’s home?(Required)

Yes

No

Are there any domestic hygiene issues or concerns in the home?(Required)

You may select more than 1 choice.

No domestic hygiene issues identified

Mould

Vermin

Broken toilet facilities

Unsure

Other

Other domestic hygiene issues or concerns in the home(Required)

Does the client or other residents of the home smoke or vape on the premises?(Required)

Yes

No

Unsure

Are there any pets in the home?(Required)

Yes

No

Can the animal/s be put in a room or outside prior to a visit if requested?(Required)

Yes

Unsure

Are there any other occupants or visitors likely to be present during home visits?(Required)

Yes

No

Do any of these occupants or visitors pose a threat or risk to Melior staff?(Required)

Yes

No

Please describe the threat or risk.(Required)

Are there any known weapons kept in the home?(Required)

Yes

No

Are they securely locked away?(Required)

Yes

No

Health and behaviour history

Has the client experienced significant mental health concerns (e.g. schizophrenia, psychosis, drug-induced psychosis, suicidal ideation, self-harm). If yes, please describe.(Required)

Does the client, or other occupants of the home have a history of violent or aggressive behaviour? (e.g. verbal and/or physical aggression, weapons use, sexual violence). If yes, please describe.(Required)

Does the client or other occupants consume drugs or alcohol in a way that the behaviour would place the worker at risk? (e.g. Needle stick injury, physical aggression). If yes, please describe.(Required)

Has the client been involved in the criminal justice system. If yes, please describe the history and types of offending(Required)

Does the client pose any other risk to the practitioner? If yes, please describe.(Required)

Is there anything else that would be useful for us to know?(Required)

How did you hear about us?(Required)

Google

Social media

Word of mouth

Expos / events

Other

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Melior Positive Behaviour Support acknowledges the Traditional Custodians of the lands on which we provide our services. We recognise the unique connection of Aboriginal and Torres Strait Islander People to Country and waters, and we pay our respects to Elders past and present.

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Melior Positive Behaviour Support
32 Burton St, Cannington WA 6107, Australia
Phone: (08) 6325 4400
Email: hello@melior.org.au

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