Behaviour Support Intake Questionnaire

Behaviour Support Intake Questionnaire

Behaviour Support Intake Questionnaire

Behaviour Support Intake Questionnaire

Client Name
Client Name
First
Last
Have previous Behaviour Support Plans been lodged with NDIS Quality and Safeguards Commission?
Are there currently any Restrictive Practices used to support the person in the context of managing a behaviour of concern

Restrictive Practices

Seclusion

Seclusion is the sole confinement of a person with a disability in a room or a physical space at any hour of the day or night where voluntary exit is prevented, or not facilitated, or it is implied that voluntary exit is not permitted.

Chemical

Chemical restraint is the use of medication or chemical substance for the primary purpose of influencing a person’s behaviour. It does not include the use of medication prescribed by a medical practitioner for the treatment of, or to enable treatment of, a diagnosed mental disorder, a physical illness or a physical condition.

Mechanical

Mechanical restraint is the use of a device to prevent, restrict, or subdue a person’s movement for the primary purpose of influencing a person’s behaviour but does not include the use of devices for therapeutic or non-behavioural purposes.

Physical

Physical restraint is the use or action of physical force to prevent, restrict or subdue movement of a person’s body, or part of their body, for the primary purpose of influencing their behaviour. Physical restraint does not include the use of a hands-on technique in a reflexive way to guide or redirect a person away from potential harm/injury, consistent with what could reasonably be considered as the exercise of care towards a person.

Environmental

Environmental restraint restricts a person’s free access to all parts of their environment, including items or activities.

 

Seclusion
If yes:
If yes:
Chemical Restraint
If yes:
Mechanical Restraint
If yes:
If yes:
Physical Restraint
If yes:
If yes:
Environmental Restraint
If yes:
If yes:
Does the Restrictive Practice have state authorisation?

Behavioural Excesses

Does the person display physically aggressive behaviours (e.g. punching, kicking, spitting, scratching, throwing objects)
Does the person display verbally aggressive behaviour (e.g. swearing, shouting, verbal threats)
Does the person lie, deny or distort the truth
Does the person engage in restricted or repetitive behaviours (e.g. body movement, repeating words/phrases)
Does the person have a special interest or obsession
Does the person abscond from their environment (e.g. runaway, flee or try to escape)
Does the person refuse to engage in everyday activities/non preferred activities

Behavioural Deficits - Verbal Communication Skills

Does the person understand what other people say?
Do other people understand them?
Can the person start, maintain and end a conversation?
Can the person understand simple instructions (e.g. 1 to 2 step instructions)?
Have the ability to understand more complex instructions?
Tend to interpret things/direction and remarks literally?

Behavioural Deficits - Non-Verbal Communication Skills

Does the person make eye contact when interacting with others?
Does the person smile and laugh when interacting with others?
Does the person vary the pitch and volume of their voice when talking to others?

Behavioural Deficits - Social Skills

Can the person make and keep friends?
Does the person initiate socialisation/conversation?
Does the person have an understanding of hidden social cues?
Can the person ask for assistance, clarification or help when necessary?
Does the person say or do something that could be considered socially inappropriate?
Does the person seek out social interaction with others or do they prefer to spend time alone?
Does the person know what to do if another person approaches them to talk or play?
Does the person have an understanding of others needs in social situations (e.g. how to talk about other peoples interest, taking turns)?

Behavioural Deficits - Self Regulation and Emotion

Can the person cope with change and disruption to routine?
Can the person transition between tasks and activities?
Can the person recognise and manage their own emotions?
Can the person recognise and respond to others emotions?
Does the person deliberately hurt themselves or damage their own property?
Can the person verbalise their emotions (e.g I am feeling happy, sad, angry)?

Goals

What are the goals for the client and family?

Additional Information

Key Contacts

Please gather all necessary contact information for stakeholder contact - i.e. First name, Surname, Contact number, Email address, Business/School Name, etc.

Declaration