NDIS Referral Form – DBT Programs

Referrer Information

Name of individual making referral *

First

Last

Referrer's Business / Organisation *

If you have a self-managed plan please type "self" in the box above

Referrer's Email *

Referrer's Phone *

Participant Information

Participant/Client's Name

Participant/Client's Date of Birth *

NDIS Number

Type of NDIS Plan

Self-Managed
Plan Managed
Combination of Self & Plan Managed

Plan Managers Details

If same as referrer please type "same as referrer"

Type of Support

Individual intervention and counselling
DBT or Skills Groups
Behaviour support (including Positive Behaviour Support Plans)
Capacity and skill building (e.g. emotion regulation or social connections)
Cognitive and diagnostic assessments
Other

DBT Clinics are specialist private mental health services specialising in skills development for individuals with emotion regulation difficulties (maladaptive under-control) and difficulties with social signaling in relationships (maladaptive over-control). An assessment is performed before an individual commences our DBT or RO-DBT programs to ensure the most suitable evidence informed program for each individual.

Item Reference Number: Individual Therapy

Please provide the Item Reference Number for individual therapy identified on your participant's plan. NDIS payments system applies unique numbers for each support line item and providing the Item Reference Number will enable our accounts team to issue the correct Item Reference Number on each invoice.

Item Reference Number: Skills Group

Please provide the Item Reference Number for Skills Group identified on your participant's plan. NDIS payments system applies unique numbers for each support line item and providing the Item Reference Number will enable our accounts team to issue the correct Item Reference Number on each invoice.

Upload Supporting Documents

Click or drag files to this area to upload. You can upload up to 4 files.

Further information *

Please provide an overview of the support requested including: anticipated duration of support, special requests, oreintate DBT Clinics to any particular preferences or needs.