Supporting Information to be provided with Application when applying to use a Restrictive Intervention

	Checklist	Tick box
1	Personal Profile / contact details of person to which the Restrictive Intervention applies
2	Have you discussed with client's Nominated Person (e.g. family member, Advocate).
3	Brief description of Person's Behaviour that leads to the need to use a Restrictive Intervention (e.g. What does the behaviour look like; How often does it occur; In what environments does this occur; What is the impact of behaviour on the client; What is the impact of the behaviour on others?).
4	Description of Restrictive Intervention (e.g. Indicate if this practice is Environmental or Personal).
5	Description of impact of Restrictive Intervention on others
6	Evidence supporting application: Allied Health Professional Reports GP report Behaviour Intervention Plan Specialist reports Person responsible opinion
7	Alternative interventions trailed (e.g. different clothing; avoiding situations; distraction; staff education and training).
8	Results of trials i.e. - worked/didn't work - inks to point seven.
9	Protocol for use of Restrictive Intervention - (see example in package)
10	Evidence of staff knowledge and understanding of protocol.
11	Options available to the person and others affected by Restrictive Intervention that mitigate restriction e.g. - visual choice boards to ask for items in a locked fridge.
12	Are similar interventions in place for the client in other services accessed by the client – include relevant information.