ALVARRA HEALTH AND WELLBEING

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New Participant Intake Form / Referral Form

Thank you for choosing Alvarra Health & Wellbeing.
Please fill out the intake form below with as much information as possible. This helps us better understand and get to know the person you’re referring and how we can best support them.

Once we receive the referral, a member of our team will be in touch within 2 business days to discuss the next steps and answer any questions you may have.

If you have any questions or need help filling out the intake form, feel free to contact us on 📞 0492 985 372 or ✉️ connect@alvarra.com.au
We’re here to help.

Alvarra Health & Wellbeing operates in line with the NDIS Practice Standards and Code of Conduct, ensuring all support is delivered safely, ethically and with respect for participant rights.

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Referrer Name *

First

Last

Referrer Email *

Confirm Email

Referrer Phone Number

Role & Organisation

Participants Full Name *

First

Last

Participants Date of Birth (DOB) *

Participants NDIS # *

if Details to

NDIS Plan Dates (Start and End) *

Participants Address *

Participants Gender *

Participants Current Living Situation *

Family Home
SIL
SDA
Independent Living
Other

Primary Support Providers (if applicable)

Preferred Communication Method:

Verbal
Visual
AAC
Written
Other

Interpreter Required?

Primary Language (if not English)

Cultural and Religious Details

Diagnosis & Relevant Medical Information *

Current Stakeholders Involved (eg. GP, School, Psychiatrist, Allied Health) *

Restrictive Practices in Place? *

Yes
No
Unsure

Are Any Restrictive Practices Currently Unauthorised, Informal, or Undocumented? *

Yes
No
Unsure

Restrictive Practices if Known

Known Risks or Safety Concerns (tick all that apply) *

Aggression towards others
Self-injury
Property Damage
Absconding/ Elopement
Sexualised Behaviours
Substance Use
Fire Setting
Safeguarding/ Abuse Concerns
None Known
Other (please specify below)

Risks and Safety Concerns Additional Information

Has the Participant Previously Received Behaviour Support *

Yes
No
Unsure

Has a Behaviour Support Plan Been Written *

Yes
No
Unsure

Date of Most Recent PBSP

PBSP Author and Provider Details

Can a Copy Be Shared With Alvarra Health & Wellbeing

Yes
No
Pending Consent

Emergency Contact Full Name *

First

Last

Emergency Contact Phone Number *

Relationship to Participant *

Support Coordinator Name (if applicable)

Support Coordinator Email

Support Coordinator Phone Number

Support Coordinator Company Name

Who is Legally Authorised to Make Decisions for the Participant *

Participant (Self-Decision Maker)
Parent/Carer (for Child Under the Age of 18)
Parent/ Carer/ Informal Decision Maker
Guardian (Appointed)
Office of the Public Guardian (OPG)
Other (Please Specify Below)

Additional Information for Decision Maker

If Participant is Decision Maker, Do They Require Support to Understand or Consent to Services?

If Yes, Please Describe Supports Required (E.G. Easy Read, Visual Supports, Advocate Present)

Funding - Improved Relationships Positive Behaviour Support *

Funding Management Type *

Self Managed
NDIA Managed
Plan Managed (Please Provide Details Below)

Plan Managed Details - Including Name, Email Address & Phone Number

Funding Line Item *

Other Funding Details

Please Provide Funding Amount for Each Line Item (Hours & Monetary Value) *

PACE Participant *

Yes
No
Unsure

When Do You Require Behaviour Support Services to Commence

Preferred Service Delivery Mode *

In-Person
Telehealth
Mixed

Preferred Primary Contact for Behaviour Support Coordination *

Participant
Family
Support Coordinator
Service Provider
Other

Preferred Contact Method

Phone
Email
SMS

Who Will Be Implementing the Behaviour Support Plan? *

Family
Support Workers
Mixed Supports
Unknown

Are Implementers Registered NDIS Providers *

Yes
No
Mixed
Unsure

If you have any questions or issues with this form please email: connect@alvarra.com.au or call 0492 985 372

ALVARRA HEALTH & WELLBEING

Not Just Plans – People, Purpose, Progress

Phone: 0492 985 372 | Email: connect@alvarra.com.au | ABN: 73 687 712 876 | NDIS ID: 4-LF9BJDI

Alvarra® is a registered trademark of Alvarra Health & Wellbeing Pty Ltd.

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