Behaviour Support Plan
Person’s name:
Date of
Birth:
Title
First Name
Surname
dd/mm/yyyy
Address:
CRIS
Number:
Street no. Street
Suburb
Postcode
Review
Date:
Behaviour Support
Plan Date:
dd/mm/yyyy
dd/mm/yyyy
Plan Prepared By:
Contact
Title
First Name
Surname
Position and
Agency/Organisation
List all agencies/
Disability Service
Providers who would
implement supports in
accordance with this
plan:
Lead Agency/ Disability
Service Provider
address:
Phone:
Street no. Street
Suburb
Postcode
People consulted in
developing the plan:
Name, Position/relationship
Assessment Report/s
used: (Include title,
author and date of
reports.)
Title, author, dd/mm/yyyy
Is more than one Disability Service Provider, agency or setting proposing to use Restrictive
Interventions?
Yes
No
If yes, who? (List all settings/agencies which propose to apply restrictive interventions)
Approving Authorised Program Officer/s:
(List names of all APOs who approve the proposed Restrictive Interventions contained in this plan)
APO Name
Position Title
Disability Service provider
Authorised Program Officer must complete APO Approval and Checklist on Pages 2 – 3.
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Office of The Senior Practitioner
Department of Human Services
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Behaviour Support Plan
PART A:
Authorised Program Officer Approval and Checklist
This approval form and checklist covers relevant legal obligations and responsibilities of the
APO in approving the use of Restrictive Interventions within the Behaviour Support Plan. In
approving the use of Restrictive Interventions, the APO should be satisfied that the plan
addresses the clinical and person centred support needs of the person to whom it applies.
Please sign a separate APO Approval and Checklist form as applicable to each setting/agency, which
proposes to use restrictive interventions as described within the Behaviour Support Plan.
Sec 140:
I approve the use of restrictive interventions to be applied within:_______________________
____________________ (add setting or service outlet) of:______________________ (add
name of your agency/Disability Service Provider) as proposed within the Behaviour Support
Plan, for the period ___/___/____ to ___/___/____
Additional Comments:
Use this space to add comments or recommendations you consider necessary. For example factors to be considered in
the plan when it is reviewed.
Sec 141:
I am satisfied that this Behaviour Support Plan adequately addresses the following provisions
of the Act:
Sec 141 (2): The BSP include information which:
(a) state the circumstances in which the proposed form of restraint or seclusion is to be
used for behaviour management;
(b) explain how the use of restraint or seclusion will be of benefit to the person;
(c) demonstrate that the use of restraint or seclusion is the option which is the least
restrictive of the person as is possible in the circumstances
Sec 141 (3):
I am satisfied that the person/s responsible for developing the Behaviour Support Plan
has/have consulted adequately with:
(a) client/person with a disability;
(b) person’s guardian, if there is one;
(c) a representative of all other DSP who are involved in the person’s life; and
(d) any other person integral to the development of the BSP.
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Department of Human Services
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Behaviour Support Plan
Sec 143:
Independent Person
I have ensured that Mr/Ms _____________________ who is_________________ (state
relationship to client, e.g. friend, parent, relative, community member etc) was present as an
independent person on ____/____/_____ (Date) to explain to the person with a disability for
whom this BSP applies, the inclusion of proposed use of restraint or seclusion and all other
requirements as stated under Sec 143 (1) of the Act.
Sec 145 (3):
I confirm that ___________________________ (state who has sent the advice) arranged for
Mr/Ms_______________________ (insert person’s name) to receive written advice of the
inclusion of RI and/or seclusion in this BSP at least two days prior to enacting the proposed
use of restraint and/or seclusion.
OTHER COMMENTS AND RECOMMENDATIONS
__________________________
Signed
_______________________
APO Name
Date: ___/___/_____
_______________________
APO Title
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Office of The Senior Practitioner
Department of Human Services
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Behaviour Support Plan
PART B:
SECTION 1: ASSESSMENT
1.1 Nature of disability/disabilities
(Include level of intellectual disability, mental health status, medical, communication abilities, strengths and weaknesses)
1.2 Person’s goals
(Include here all individual aspects about the person, in terms of work, school, recreation. What kinds of activities does
the person enjoy?)
1.3 Behaviour/s of Concern
Based on Functional Behavioural Assessment:
a) Describe the behaviour/s of concern.
b) Briefly describe the impact of the behaviour on the person and others.
c) What are the predictors for the behaviour? (What are the situations in which the behaviour is likely to occur?).
d) Frequency or intensity or duration of behaviour (daily, weekly etc).
1.4 Observation and Analysis
a) Those who know the person well believe the behaviour of concern occurs because: (What is the function of the
behaviour ie. to avoid something, to act out confusion, to gain intimacy).
b) What environmental changes, structure and supports are needed to stop the person using this behaviour? (What
changes need to occur with and around the person in order to remove the likelihood of behaviours of concern).
c) Critical alerts: Other behaviours to be aware of.
SECTION 2: POSITIVE INTERVENTIONS
2.1 Alternative behaviours that meet the same need
a) What should the person be doing INSTEAD of the behaviour of concern? (How should the person get their needs met in
an acceptable way?)
2.2 Positive strategies
a) What strategies need to be developed? (ie. in order to teach an adaptive behaviour, what steps need to be taken?)
Provide a summary of steps with reference to the person’s individual support plan or attach a copy of the strategies.
b) Who is responsible for implementing the program?
SECTION 3: RESTRICTIVE INTERVENTIONS
3.1 Restrictive interventions
a) What restrictive interventions will be used? (List least restrictive first e.g., self-management prompt first, then to
assistance etc.)
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Behaviour Support Plan
b) Why is the restrictive intervention being used?
c) Circumstances under which the restrictive intervention will be required.
d) What measures will be used to monitor the effect of the restrictive interventions?
e) How and when is it to be reviewed?
f) Who authorises the restrictive interventions?
SECTION 4: REVIEW: EVALUATION OF INTERVENTIONS
4.1 Results of positive interventions
a) What works well in reducing behaviours of concern? (What evidence will be used to measure this?
b) What doesn’t work well to reduce behaviours of concern? (what evidence will be used to determine this?)
4.2 Results of restrictive interventions
a) What was the effect of the restrictive intervention on behaviours of concern? (in the short term and in the longer
term?)
b) What was the effect of the restrictive intervention on the person’s quality of life (might consider some of Schalock and
Alonso domains: e.g., Physical Well-Being, Emotional Well-Being, Relationships with others, being included).
SECTION 5: REVIEW
5.1 Assessment
Observation and analysis conclusion:
Do changes need to be made to existing programs / behaviour support plans?
What needs to change?
Yes
No
Are environmental supports or changes necessary?
Which are needed?
Yes
No
Is this level of restrictive intervention still required?
What level is required?
Yes
No
Is the restrictive intervention still required?
When was it required last? (date)
Yes
No
5.2 Follow-up
a) What changes need to be made to the BSP?
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Department of Human Services
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