Test - Liberty Behavioural Services

Let's get the ball rolling for you as quickly as possible with a few questions

Your Details:

I am the:*

First Name*

Last Name*

Phone Number*

Email Address*

Support Coordinator Details

Support Coordinator details (if applicable)

First Name

Their Email

Phone Number

I confirm that this referral is not for an Early Childhood Intervention Plan (these plans are not eligible for our services)

I confirm that this referral is not for an Early Childhood Intervention Plan (these plans are not eligible for our services)*

How did you hear about Liberty text

Supporting Person

Thanks! Now let's find out about the person we will be supporting:

First Name*

Last Name*

NDIS Number*

Date of Birth*

Funding Confirmation

This participant has NDIS behaviour support funding.

Please ensure the address below is absolutely accurate as it will help us determine which practitioners are available in that area

Address*

Suburb*

Postcode*

State/Territory:*

Person Identification

This person identifies as a First Australian This person identifies as a member of the Culturally and Linguistically Diverse Community This person identifies as being LGBTQiA

Is there anything you would like to share with us that may help us better support you?

**We follow the NDIS price guide and terms and conditions, these cover how we deliver services both face to face and non face to face, travel and cancellations.

*We follow NDIS price guide and terms for face-to-face and non-face-to-face services, travel, and cancellations. Remote locations have different hourly rates per the NDIS price guide.

**We follow the NDIS price guide and terms and conditions, these cover how we deliver services both face to face and non face to face, travel and cancellations.

We provide face-to-face services across most of Australia but currently offer only Telehealth in ACT, NSW (except in-person in Newcastle), NT, and rural SA. In Queensland, in-person services are available within 30 minutes of Southwest Metro Brisbane, with Telehealth for the rest of the state.

*We follow NDIS price guide and terms for face-to-face and non-face-to-face services, travel, and cancellations. Remote locations have different hourly rates per the NDIS price guide.

We provide face-to-face services across most of Australia but currently offer only Telehealth in ACT, NSW (except in-person in Newcastle), NT, and rural SA. In Queensland, in-person services are available within 30 minutes of Southwest Metro Brisbane, with Telehealth for the rest of the state.

**We follow the NDIS price guide and terms and conditions, these cover how we deliver services both face to face and non face to face, travel and cancellations.

Person's support needs text

Person's disability/diagnosis text

Risks of harm selection

Did physical aggression towards others result in hospitalisation?

If yes to any of the above, please describe the behaviour(s). Note that for risk management reasons, Liberty will not be able to begin services until this box is filled in appropriately.*

Please upload any BSPs, Allied Health Reports, or behavioural incident summaries you have.

Click to choose a file or drag here

Are there any Regulated Restrictive Practices being implemented by NDIS funded services?

Please describe the restrictive practice:

Is the company that is providing support workers that engage in the restrictive practices a registered or an unregistered provider of restrictive practice?

Unregistered provider of Restrictive Registered provider of Restrictive Practices

Known risks to NDIS providers:

Obstructed exits Aggressive animals on the property Isolated/remote location Weapons on-site Decreased mobile reception Are there known risks posed by other residents that we should be aware of?

Please describe the known risk(s) to NDIS providers:

What additional things should we know?Please note that Liberty may cease services for non-disclosure of known risks. Liberty strictly follows NDIS privacy guidelines when handling participant data.

In the last 2 years, this person has been involved with the Juvenile or Adult Justice System In the last 2 years this person has been involved with Child Protection This person has a history of sex offences or inappropriate sexual ideation This person is currently on a CCO (Community Correction Order) or Parole order (if so please list the relevant contact people to speak to in relation to this in the box below)

Please describe the additional things we should know about:

Is it safe for staff to be left alone with this person?*

Yes, it is safe for staff to be left alone with this person Sometimes it is safe for staff to be left alone with this person No, there need to be 2 people present at all times

Describe Why not safe

Final questions, all answers must be correct to avoid service delays:

Who is authorised to sign the service agreement?*

Legally Appointed Guardian (NOT Public Guardian / Public Advocate / Child Protection Guardian) Public Guardian / Public Advocate / Child Protection Guardian) Participant Parent (child under 18) Plan nominee (as per current NDIS plan)

Details of the authorised person

First Name*

Last Name*

Email Address*

Phone Number*

Please upload a screenshot of the current funding from the NDIS portal*

Click to choose a file or drag here

This section below is where we find most people make mistakes.

Most errors happen when people rush— so that we do not have to send out several service agreements for signing (which can be frustrating for people signing), please take a moment to
check every detail including remaining available funding in the portal .

The details you enter below will automatically become the legal service agreement.

Is this a PACE/Non PACE plan?*

Funding type:*

IDL funding can be used to write a Behaviour Support Needs Assessment (up to 3 months), which can allow you to apply for appropriate Behaviour Support funding, it cannot be used for on-going Behaviour Support.

Please specify hours available for an Improved Daily Living report (10 hours minimum, 20 hours maximum. Please do not write 0 as this number will be automatically entered into the Service Agreement and we will need to send an additional Service Agreement for signing which can be frustrating for people signing)*

Please upload a screenshot of your Improved Daily Living funding as per the examples below*

Click to choose a file or drag here

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COMPULSORY FOR PACE PLANS POST 19 MAY 2025: Are payment periods monthly, quarterly, or yearly:

COMPULSORY FOR PACE PLANS POST 19 MAY 2025: Specify current amount of funding per period (e.g if plan periods are quarterly, please write Q1: X amount, Q2: X amount, Q3: X amount Q4: X amount)

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(PACE) Please write amount & available balance as shown in the example below which you can find in your provider portal

Amount

Available

Stated hour for behave

Stated hours special

Non-PACE plan: If you are transferring from a different provider please ensure that the funding has been released so we can create a new Service Booking.

I confirm that the funding has been released OR the funding has not yet been released and I understand it must be released before services can commence.

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Non-PACE plans: (please use provider portal to answer the questions below)

Funds Approved $ for Specialist Behavioural Intervention Support (see online portal)

Funds Approved $ for Behavioural Management Plan (see online portal)

Stated hours for Behavioural Management Plan (see online portal)

Stated hours for Specialist Behavioural Intervention Support (see online portal)

NDIS plan start date:*

NDIS plan end date:*

Funding managed by:*

Name of plan manager:

Plan manager email: *

Plan manager phone:

PACE plan

PACE plan:Alongside a Service Agreement, the key decision maker must endorse Liberty. This is mandatory before services can begin. Endorse Liberty quickly with these steps*

Funding Info Confirmation

⚠️ To avoid having to resend multiple versions of the service agreement for signing (which can be frustrating for already very busy parents/key decision makers), I confirm that all the funding information provided is accurate. ⚠️

Do you have a preference for the gender of the practitioner? (Leave blank if no preference). Note that we will do our best to meet your request.

Male Female Non-Binary Inter-sex

Do you have any questions/feedback/requests?

If there is a specific Liberty practitioner you would like to request please enter their email below:
(not their name, just email please)

In case no practitioners are available in the participant's region, I would be open to receiving services via Telehealth (video calls)

Yes No

If you are a Liberty team member please write your email below

⏰ I understand that this team is in high demand and to secure this spot I will ensure that the service agreement and NDIS endorsement (for PACE plans) occur as soon as possible.*

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