Capacity Enquiry and Referral Form

Date of Referral *

Is this a capacity enquiry? *

Is this a re-referral for a previous/existing Positive Caring Services Client? *

Thank you for your NEW CLIENT referral

Thank you for re-referring your client for Services

Have any contact details changed for the Client within last 3 months? *

YesNo

Are there any risk changes to the environment? *

YesNo

Are there any changes to the Services Required? *

YesNo

If you have submitted an Enquiry that has been accepted, you have been directed back to this page to complete the Full Referral. Please change the dropdown option of "Is this a Capacity Enquiry" to "No - specific Referral".

The notes on accepting this Enquiry to become a Referral from our Manager are:

{{capacity notes to referrer}}

You have been directed back to this Referral to add or amend the information required as per these notes from our Manager:

{{please describe what further info is required from referrer}}

Client Details

First Name *

Last Name *

Known As

Date of Birth *

Gender

MaleFemaleOther

Pronouns

He/HimShe/HerThey/ThemOther

Phone Number *

Email *

Updated Phone Number *

Updated Email Address *

Address *Please include any specifics re parking or access

Updated Address *Please include any specifics re parking or access

Updated Reason for Referral *

Other Information

Type of Accommodation

Supported LivingAt home with familyIndependentlyOther

Do you identify as ATSI?

YesNo

Communication Method *

VerbalNon-VerbalBoth

Is communication support required? *

YesNoSometimes

Which language is spoken at home?

Is a translator required?

YesNo

Preferred Method of Communication *

If other please specify

Client Mobility *

IndependentlyWith SupportWheelchairOther

If other please specify

Additional Comments

Legal Guardian / Client Representative (if applicable)

First Name

Last Name

Email

Phone Number

Relationship to Client

Referral Information

Please choose the Service/s required *

Specialist Behaviour Support Practitioner ServicesBehavioural Management Plan and TrainingSocial WorkCounselling

Is there an existing Behaviour Support Plan in place? *

Yes No

Primary Diagnosis as recognised by NDIS/Specialists *

Relevant Medical History *

Any reports or documents that may assist with services for the Client

Browse

Please choose the Service/s required *

Specialist Behaviour Support Practitioner Services Behavioural Management Plan and TrainingSocial WorkCounselling

Please provide more context regarding new needs *

Any updated reports or documents that may assist with Services for the Client

Browse

Capacity Enquiry

Diagnosis of Client requiring Services *

Reason for Capacity Enquiry *

Specialist Behaviour Support Practitioner ServicesBehavioural Management Plan and TrainingSocial WorkCounselling

Funding for the Client *

NDIS Self ManagedNDIS Plan ManagedNDIS Agency ManagedPrivate

Please describe the situation and provide an ideal time frame *

Enquirer Name *

Enquirer Phone

Enquirer Email *

Client Representative

Please fill in if there has been a change in Representative, else leave blank if previous Representative recorded still appropriate

First Name

Last Name

Relationship to Client

Contact Phone Number

Contact Email

Referrer Details

Is this a self-referral *

First Name *

Last Name *

Organisation

Referrer's relationship to Client *

Other relationship

Referrer Phone

Referrer Email *

The person being referred has given consent to this referral and consents to these details being kept on a cloud based client management system *

Funding Information

Has the Client changed funds management?

Yes - new details to be providedNo - same funds management as last Plan

Funding Source *

NDIS Self ManagedNDIS Plan ManagedNDIS Agency ManagedPrivate

Change in funds management *

NDIS Number *

Plan Start Date *

Plan End Date *

Plan Management Company *

Invoicing Email *

We will help you to endorse PCS as a MyProvider so we can claim invoices from the PRODA/PACE Portal.

Newly Agency Managed so we will help you to endorse PCS as a MyProvider so we can claim invoices from the PRODA/PACE Portal.

Plan Management Company *

Updated Invoicing Email *

Estimated Budget Allocated for Requested Services - $ or hours

Category for NDIS funding

If CORE Supports are to be used - please provide evidence of approval *

Who shall we send the Service Agreement to? *

Who is the best contact for arranging appointments? *

If the Client consents, please upload a copy of the NDIS Plan if able

Browse

If Client consents, please provide a copy of the New NDIS Plan if able

Browse

Risks

If you have answered yes or unsure to any of the above questions, please include more information here *Please provide explanation in as much depth as possible

I will liaise with the Therapist to provide a support person for all visits for this Client *

Director Review Capacity Enquiry

The Client is suitable for Referral *

Yes - this referral form sent back for completionNo - send polite declineNeeds liaising with Enquirer

Thank you - an apology for lack of capacity will be sent to the Enquirer

Thank you - this Referral form will be sent back to the Enquirer

Capacity Notes to Referrer *Please pop a note in here for the Enquirer

Name of Enquirer

Liaise via Phone

Liaise via Email

Review by Director

This Client is suitable for Services

YesNoNeed further info

Please describe what further info is required from referrer *Please be aware this text is sent to referrer on the workflow email

If no, please provide reasoning *

Any further information?

Director Finalisation

Next Steps

Admin setup case file in Splose/AsanaAdmin accept immediatelyAdmin add to Waitlist in SploseAdmin send SA - please specify below

Admin send Consents x 2 (1 x PCS & 1 x NDIA if NDIS)

Hours or Dollars for SA - and any other requests or notes

Admin Actions

First Steps

Setup file in Splose Reason for Referral added to 'Other Details' during setup, also with tags;SC and NOK details added to Other Info;Attached files uploaded (create a Referral Information folder if required) including Ref Form that comes through when completed;Any extra emails re this referral in admin@ added to Files - Correspondence Folder (create if needed).

Add to Waitlist in Splose - Waitlist tag in Splose client file and Asana

This Client is SELF MANAGED - please assign the client as "Send Invoices to"

This Client is AGENCY MANAGED - please assign NDIA as "Send Invoices to"

Case budget setup in Splose.
- Please title Surname dd.mm.yy - dd.mm.yy (if more than one Service name as eg: Surname Behaviour dd.mm.yy etc)
- Type: Hours
- Case Alert: 70% funding used, 4 weeks from End of Plan, for Sheree

Service Booking created on PRODA Portal
(CB Daily = CB Daily, CORE = Daily Activities)

Second Steps

Client->Phone number added as Mobile number;Risks added to the Alerts box;NDIS No. copied into extra invoicing details (if NDIS);

Support Activity - "Therapeutic Report due - 6w until EOP" created and assigned (marked as do not invoice).

Date Calculator for easy date generation for EOP reminders

Relevant PBS alerts added to Calendar - Therapeutic Report due - 6w until EOP & 3m until EOP (and marked as do not invoice)

Asana setup PBS Client - duplicate task "PBS Client" to have the relevant subtasks

Asana setup SW/Counsel Client just as adding a new task in Active Clients

Please choose required:

NDIS SA LINK HERE

PRIVATE SA LINK HERE

SA sent

Sent Service Agreement for signing - Please add 'Pending SA' tag in Splose and Asana - include link to SA in Alerts

Consents please prefill with as much info as possible (please complete before finalising this Setup so as to gain the links required for the next step):

NDIA Consent

PCS Consent

Consents x 2 sent

Sent 1x PCS Consent and 1 x NDIA Consent (if NDIS) for signing as replacing the *text in the Splose emails below, and in the Splose Alerts text, and in Asana with the links you've copied from the Workflow Consent emails

Please send Waitlist NDIS email

Please send Welcome email from Splose

Please send Waitlist email Private

Admin completing this form

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