Service Enquiry

Enquirer's Name

First Last

Phone

What type of service are you enquiring about?

What is your relationship to the prospective client?

Do you have consent to share information

What is the prospective client's age?

What is the prospective client's location (suburb)?

What is the prospective client's disability?

Briefly describe the prospective client's current living situation (with family, independently, type of supported living etc.)

Please describe current supports, service hours and services involved (support workers, allied health, government agency, advocates, other)

What has prompted the request, at this time, has there been a change in the situation or services?

How do you hope the support from Lancaster Consulting may help to improve the prospective client's quality of life/situation?

What are the behaviours of concern? Please provide specific examples.

What is the impact of these behaviours on the prospective client?

What are the goals for the behaviour support or support coordination service?

Do you have NDIS or State funding? How many hours are available for support?

Please describe the supports that will implement the behaviour support plan

Restrictive Practices

For behaviour support requests, are there any restrictive practices that you are aware of, if so, what are they?

CAPTCHA

Important note: Please do not close this page after you have clicked the submit button. It will automatically redirect you once the form has submitted successfully.