Melior Referral Form

Please complete the Melior Referral Form as required. Our waitlist is open for early 2027 as our new to the sector PBS Practitioners will have capacity then.

As new PBS Practitioners in the field, they are supervised closely by our team leaders at Melior, and are supported in their work every step of the way, so you can be assured that your experience with Melior will be of the highest standards and quality.

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

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Hidden Fields for Lumary

Reason for Enquiry

Source of Enquiry

Requested Service

Date(Required)

I am referring...(Required)

Myself

Someone I know

Have you/the Client received PBS services before?(Required)

Yes

Do you currently have a PBS Plan?(Required)

Yes

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

Other relationship to client/participant(Required)

Client / Participant Details

Client's name(Required)

First Last

Gender(Required)

Male

Female

Non-binary

Prefer not to say

Other

Date of birth(Required)

Phone number(Required)

Please add only one phone number. If you have additions details or phone numbers you would like to add, please add it in the text box below for "Tell us about you/the client".

Client email(Required)

Is the client contactable?(Required)

Yes

Unsure

Client preferred communication channel(Required)

Phone

Do not contact

Client's address(Required)

Suburb ZIP / Postal Code

NDIS number(Required)

How is funding managed?(Required)

Total allocated amount of PBS hours/funding in NDIS plan (Specialist Behaviour Intervention, and Behaviour Management & Training)(Required)

Remaining amount of funding in NDIS plan(Required)

Start date of NDIS plan(Required)

End date of NDIS plan(Required)

Tell us about you/the client(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

Do not contact

Primary contact: Relationship to client(Required)

Select the most relevant option

Partner

Parent

Family

Carer

Guardian

Other

Primary contact: Other relationship to client(Required)

Information to assist us to determine suitability & support needs

What are the three main behavioural concerns?(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

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

Unsure

Are there any pets in the home?(Required)

Yes

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

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

Yes

Please describe the threat or risk.(Required)

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

Yes

Are they securely locked away?(Required)

Yes

Health and behaviour history - This information can assist us to link you/the client with a suitable practitioner.

Has the client experienced significant mental health concerns (e.g. schizophrenia, psychosis, drug-induced psychosis, suicidal ideation, self-harm). If YES, please describe. If NO, please move to the next question.

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. If NO, please move to the next question.

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. If NO, please move to the next question.

Has the client been involved in the criminal justice system. If YES, please describe the history and types of offending. If NO, please move to the next question.

Does the client pose any other risk to the practitioner? If YES, please describe. If NO, please move to the next question.

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

How did you hear about us?(Required)

Google

Social media

Word of mouth

Expos / events

Other

CAPTCHA

Melior Referral Form

Hidden Fields for Lumary

Referrer Details

Client / Participant Details

Primary contact details

Information to assist us to determine suitability & support needs

Place of residence

Health and behaviour history - This information can assist us to link you/the client with a suitable practitioner.

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