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Referral IPA - Last updated May 2025
Date
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DD
/
MM
/
YYYY
Agency
*
Overwrite the above if not DCJ
Branch / CSC
*
Address
*
Referrer/Caseworker's name
*
Phone:
*
Email
*
Emails to send invoices
*
Please add any other emails for the people to whom this quote should be sent
Does medication need to be administered?
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Yes
No
If yes, these will need to be Webster packed as Impact will not be able to administer them legally if they are not
Any psychotropic medication?
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Yes
No
Please, upload authorisation to administer psychotropic medication form
Any behaviours of concern?
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Yes
No
Please elaborate and upload any relevant documents at the bottom of this page (Behaviour Support Plan or Safety Plan)
*
Period of support requested
Start Date
*
DD
/
MM
/
YYYY
End Date
*
DD
/
MM
/
YYYY
CHILD OR YOUNG PERSON'S INFORMATION
First name
Family name
Date of birth
Age
Cultural identity
Self identified gender
CYP 1
CYP 2
CYP 3
CYP 4
SUPPORT
Type of support required:
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Two carers / one CYP
One-on-one
Other
Overnight awake shifts needed?
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Yes
No
If two-on-one, will both carers be required to stay awake overnight?
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Yes
No, only one carer
No, sleep over only
Extra daytime support hours needed?
This would be in addition to the above
*
Yes
No
Unsure. To be discussed
Hours needed from
HH
:
MM
AM
PM
AM/PM
to
HH
:
MM
AM
PM
AM/PM
Preferred area
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Central Coast
Hunter
South Western Sydney
Western Sydney
Other
Full accommodation required (fully furnished house, food and general entertainment, car)
*
Yes
No, please quote for car and food only
Impact may not have a car available. If that is the case
*
Please organise a rental car and quote accordingly
We will organise the car
Please note that if the placement is for longer than a month, Impact will most likely purchase a car for that program. The cost will reduce accordingly.
Estimated average daily kilometres for regular trips (school, etc)
*
Please add any relevant information
Attach relevant documentation (CIF, CAT, etc...)
*
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