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Referral + Consent Form

Was this referral recommended at a CTR?
Yes
No
If 'Yes', when was the CTR meeting held?
Day
Month
Year
If you are referring a child/young person, are they subject to any of the following (please select any that apply)
If CP, please select the category from the below options:

Contact Details – we will require contact details of the person we need to contact to begin assessments/intervention. For example, Parent or Keyworker

Personal Details of Referred Individual

Date of Birth of the Referred Person
Day
Month
Year
Is this a service or parental address?
Service
Parental address
Other
Responsible for funding (please choose one option)
Integrated Care Board (ICB)
Local Authority
Social Care
Private funding* (Please note 50% of private funded assessments need to be paid for before the assessment commences and the reaining 50% after).
Other (please specify below)
Why is the person being referred?
Please tick all the behaviours that the referred person displays
Diagnosis: Please list all known formal diagnosis including any current or recurring physical health issues
Are there any risks or allegations that professionals working with this person or attending their house that we should be aware of?
Yes
No
Consent to see the individual referred obtained?
Yes, i have obtained their consent
No, i have NOT obtained their consent
I am doubtful about the person's capacity to consent
Permission to share information with other professionals and Circle of Support (COS) as appropriate
Yes, I have obtained permission
No, I have NOT obtained permission
I am doubtful about the person's capacity to give permission to share information
What type of service are you seeking with us?

Consent for Positive Behaviour Support


Positive Behaviour Support (PBS) is an approach designed to support individuals with autism, learning disabilities, and a range of complex care needs. The aim of PBS is to create a ‘good fit’ between the person and their environment to enhance their quality of life. Positive Behaviour Specialists Ltd is a team of MSc Behaviour Analysts who apply evidence-based Positive Behaviour Support strategies to improve the lives of individuals with autism and/or learning disabilities.


The Assessment Process

Positive Behaviour Support begins with a detailed Functional Behaviour Assessment (FBA) or Skill Assessment. This assessment helps us identify areas where the individual may experience challenges, and behaviours may serve as a form of communication. Our approach is comprehensive and involves various methods, including:


  • Interviews with individuals who know the person well (e.g., family, support staff, teachers, professionals).

  • Reviewing existing reports such as clinical assessments, speech and language assessments, incident and risk reports, and more.

  • Structured interviews with those who have observed the behaviours of concern.

  • Direct observation, either in-person or through virtual means, with data collection to analyse the behaviour(s) of concern.


At Positive Behaviour Specialists Ltd, we leverage a hybrid approach that combines virtual and in-person services, allowing for flexible and cost-effective solutions. Here's how this benefits you:


  • Virtual Observations and Meetings: We use secure online platforms (e.g., Zoom) to conduct interviews, meetings, and observations. This helps reduce travel-related costs (e.g., zero or minimal mileage fees) while maintaining high-quality service delivery.

  • In-Person Visits: Where necessary, our Behaviour Analysts will schedule in-person observations or meetings for more detailed assessments, ensuring that we fully understand the individual’s needs.

  • Skills Development Training: We offer a combination of virtual and in-person training for families, support staff, and professionals. This flexible training format is designed to be convenient and cost-effective, with minimal in-person consultancy hourly fees, saving you both time and money.



Time Frame for Assessment

Typically, the FBA is completed over a period of 5–10 days, (for skills assessments 2-3 days) from the start of our involvement (depending on the complexity of the case). These days may be spread out over a couple weeks. During this period, we gather the necessary information, which is then used to develop a Positive Behaviour Support Plan tailored to the individual's needs.


It’s important to note that the assessment process is ongoing. We will continue to collect information and data throughout our involvement, allowing us to track progress and adjust the support plan as necessary.


Protection of Personal Information

We take the security and privacy of all personal information seriously. Here's how we protect your data:


  • Secure Storage: All data will be securely stored on a cloud-based platform. We only share information with relevant professionals when necessary to support the individual’s treatment.

  • Secure Communication: If sharing information is required, we ensure security by limiting the amount of personally identifiable information, using password protection.

  • Hard Copies: If written records are required, they will be digitised and securely transferred to our storage platform. Any hard copies will be securely disposed of promptly.


Your Rights Regarding Consent and Personal Information

You have the following rights concerning your consent and the personal information we collect:


  • Revoking Consent: You can revoke your consent, either partially or entirely, at any time by informing us in writing.

  • Access to Information: You have the right to request copies of the information we have collected, including assessments, support plans, and case notes.

  • Privacy Protection: We will never use your personal information for marketing purposes. We fully comply with GDPR and other relevant data protection laws to safeguard your sensitive information.


Cost-Effective Services

Our hybrid approach ensures that we provide flexible and cost-effective services by minimising the need for frequent in-person consultations and reducing travel-related costs. This not only ensures high-quality, evidence-based support but also helps you manage costs effectively.


Consent Form

By filling out this consent form, you agree to the following:


  • I consent to Positive Behaviour Specialists Ltd conducting a Functional Behaviour Assessment (FBA) and/or Skills assessment for the individual referred.

  • I understand that a hybrid approach, involving both virtual and in-person services, will be used to carry out assessments and provide support.

  • I acknowledge that my personal data will be handled in accordance with data protection laws, including GDPR, and stored securely on a cloud-based platform.

  • I am aware that I can revoke this consent at any time and request copies of any information collected about the individual.

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