Participant Participant First Name Participant Last Name Date of Birth Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Parent or Guardian Name Street Address Suburb Phone Number Email Type of Disability Acquired Brain Injury ADHD Asperger's Autism Spectrum Disorder Cerebral Palsy Down Syndrome Epilepsy Foetal Alcohol Spectrum Disorder (FASD) Intellectual Disability Learning Disability Mental Health Physical Disability ie visual, hearing impairment Other Contact and Referrer Contact Person Name Contact Person Phone Number Contact Person Email Name of Referrer Referrer Email Referral Details Reason for Referral (tick all that apply) Assault or Trauma Abuse – domestic violence, sexual abuse or other abuse Accessing Sex Worker Behaviour issues, challenges, inappropriate Boundaries Cyber Safety Complaint or investigation in process Family issues Gender or Sexual identity Healthy Relationships Mental Health Protective Behaviours Puberty inc hygiene, menstruation Sexual behaviour in public Sexuality education Sexual Health Please provide a short description of Referral Reason Is the Individual aware of the referral? Yes No Referral Type NDIS Counselling Service General Counselling Unsure Reason for General Counselling NDIS is not available in my area yet Not eligible for NDIS Plan Unsure NDIS NDIS Number Do you have a current plan? Yes No End date of Current Plan Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year20192020202120222023 Do you need a quote? Yes No Do you have funding for counselling? Yes No Which Area is the funding under? Improved Daily Living Skills Improved Relationships Does the Individual need transport to attend appointments in West Perth? Yes No Office Perth Bunbury How did you learn about SECCA? * - Select -Dept of Child ProtectionDept of Communities, Disability ServicesDisability Support WorkerDoctorParentPsychiatristPsychologistSelfTeacher or SchoolInternet or Google searchOther
