Before you fill in the form This form is to be used by National Disability Insurance Scheme (NDIS) service providers to apply for authorisation for the use of restrictive practices as part of the provision of behaviour support to NDIS participants in accordance with the National Disability Insurance Scheme (Authorisations) Act 2019. All Applications for Authorisations must be submitted to the Restrictive Practices Authorisation Unit and include the following: ☐ Particulars of the restrictive practice proposed to be applied to the participant; ☐ A copy of the NDIS Behaviour Support Plan (BSP) (interim or comprehensive) that specifies the proposed restrictive practice; ☐ Disclosure Agreement signed by the participant or their guardian (RPA-2A); ☐ Evidence of consultation with the participant, their family, carers, guardian or other relevant person(s) about the use of restricted practices as a component of their BSP (RPA-2B); ☐ Particulars of the NDIS service providers who will apply the restrictive practice to the participant; ☐ A summary of every restrictive practice(s) applied (both authorised and unauthorised) for the 12 months prior to the date of this application (RPA-3). ☐ Any other information the NDIS service provider considers relevant to the application, such as reportable incidents relevant to the application. Once completed, email the Application for Authorisation together with the relevant documents to the Restrictive Practices Authorisations Unit, Northern Territory Department of Health (DoH): restrictive-practices.authorisation-unit@nt.gov.au PRIVACY This form collects information, including personal information that is necessary for administering and enforcing the National Disability Insurance Scheme (Authorisations) Act 2019. The DoH collects, holds and manages the personal information in this Form in accordance with the Departmental Privacy Policy which can be found at https://digitallibrary.health.nt.gov.au/prodjspui/handle/10137/726 and the Information Act 2002 (NT) Information Privacy Principles which can be found at https://legislation.nt.gov.au/Legislation/INFORMATION-ACT-2002.
Fields marked with caret (^) are office use only.
Office use only^
Date received ^	Click or tap to enter a date.	RPA No ^	Allocate a number

Application Details
Date	Request Type	☐ Interim ☐ Authorisation
NDIS Participant Details
Given Name Surname	Click or tap here to enter text. Click or tap here to enter text.	NDIS Participant Number	Click or tap here to enter text.
Gender	Choose an item.	Date of Birth	Click or tap to enter a date.
Address	Click or tap here to enter text.
Best Contact Method	Choose an item.	Contact Details	Click or tap here to enter text.
Indigenous Status	Choose an item.	CALD Status	Choose an item.
Primary Disability	Choose an item. Other: Click or tap here to enter text.	Order Details Expiry Date	Choose an item. Click or tap to enter a date.
Key Contact Details (If applicable)
Name	Click or tap here to enter text.	Relationship to participant	Choose an item. Other Click or tap here to enter text.
Address	Click or tap here to enter text.
Email	Click or tap here to enter text.	Phone	Click or tap here to enter text.

Guardian Details (If applicable)
Is a guardian or other legal decision maker appointed for the participant?	Choose an item.
Type	Choose an item.	Name	Click or tap here to enter text.
Email	Click or tap here to enter text.	Phone Number	Click or tap here to enter text.
Address for correspondence	Click or tap here to enter text.

NDIS Service Provider Details (SP)
SP1- Applicant Provider
Name	Click or tap here to enter text.	NDIS Provider Number	Click or tap here to enter text.
Contact Officer	Click or tap here to enter text.	Position	Click or tap here to enter text.
Address	Click or tap here to enter text.
Email	Click or tap here to enter text.	Phone	Click or tap here to enter text.
SP2- Other Implementing Provider
Name	Click or tap here to enter text.	NDIS Provider Number	Click or tap here to enter text.
Contact Officer	Click or tap here to enter text.	Position	Click or tap here to enter text.
Address	Click or tap here to enter text.
Email	Click or tap here to enter text.	Phone	Click or tap here to enter text.
SP3- Other Implementing Provider
Name	Click or tap here to enter text.	NDIS Provider Number	Click or tap here to enter text.
Contact Officer	Click or tap here to enter text.	Position	Click or tap here to enter text.
Address	Click or tap here to enter text.
Email	Click or tap here to enter text.	Phone	Click or tap here to enter text.

NDIS Behaviour Support Practitioner details
Name	Click or tap here to enter text.	NDIS Provider Number	Click or tap here to enter text.
Contact Officer	Click or tap here to enter text.	Position	Click or tap here to enter text.
Address	Click or tap here to enter text.
Email	Click or tap here to enter text.	Phone	Click or tap here to enter text.

7. NDIS Behaviour Support Plan (BSP) details
NDIS Behaviour Support Plan ID	Click or tap here to enter text.	Plan Start Date	Click or tap to enter a date.
Plan End Date	Click or tap to enter a date.	Plan Review Date	Click or tap to enter a date.
Was the participant and/or their family/guardian consulted in the development of the NDIS behaviour support plan?	Choose an item.

8. Summary of Behaviours of Concern (BoC)
BoC-1
Type	Choose an item. Other: Click or tap here to enter text.
Description of Behaviour of Concern (What does it look like?)	Click or tap here to enter text.
Background (This should explain the reasoning behind the behaviour)	Click or tap here to enter text.
Impact on quality of life (Provide a summary of how the behaviour impacts on the person’s quality of life)	Click or tap here to enter text.
Identified issues/risks (Detail what the behavioural risk/s are)	Click or tap here to enter text.
BoC-2
Type	Choose an item. Other: Click or tap here to enter text.
Description of Behaviour of Concern (What does it look like?)	Click or tap here to enter text.
Background (This should explain the reasoning behind the behaviour)	Click or tap here to enter text.
Impact on quality of life (Provide a summary of how the behaviour impacts on the person’s quality of life)	Click or tap here to enter text.
Identified issues/risks (Detail what the behavioural risk/s are)	Click or tap here to enter text.
BoC-3
Type	Choose an item. Other: Click or tap here to enter text.
Description of Behaviour of Concern (What does it look like?)	Click or tap here to enter text.
Background (This should explain the reasoning behind the behaviour)	Click or tap here to enter text.
Impact on quality of life (Provide a summary of how the behaviour impacts on the person’s quality of life)	Click or tap here to enter text.
Identified issues/risks (Detail what the behavioural risk/s are)	Click or tap here to enter text.
BoC-4
Type	Choose an item. Other: Click or tap here to enter text.
Description of Behaviour of Concern (What does it look like?)	Click or tap here to enter text.
Background (This should explain the reasoning behind the behaviour)	Click or tap here to enter text.
Impact on quality of life (Provide a summary of how the behaviour impacts on the person’s quality of life)	Click or tap here to enter text.
Identified issues/risks (Detail what the behavioural risk/s are)	Click or tap here to enter text.
BoC-5
Type	Choose an item. Other: Click or tap here to enter text.
Description of Behaviour of Concern (What does it look like?)	Click or tap here to enter text.
Background (This should explain the reasoning behind the behaviour)	Click or tap here to enter text.
Impact on quality of life (Provide a summary of how the behaviour impacts on the person’s quality of life)	Click or tap here to enter text.
Identified issues/risks (Detail what the behavioural risk/s are)	Click or tap here to enter text.

9. Summary of the proposed restrictive practices (RP)
RP-1
Restrictive practice type	Choose an item.
Restrictive practice sup-type	Choose an item. Other: Click or tap here to enter text.
Behaviours of Concern/s	Choose an item. Other: Click or tap here to enter text.	Choose an item. Other: Click or tap here to enter text.	Choose an item. Other: Click or tap here to enter text.
Choose an item. Other: Click or tap here to enter text.	Choose an item. Other: Click or tap here to enter text.	Choose an item. Other: Click or tap here to enter text.
Implementing Provider Names	Click or tap here to enter text.	Click or tap here to enter text.	Click or tap here to enter text.	Click or tap here to enter text.
RP-2
Restrictive practice type	Choose an item.
Restrictive practice sup-type	Choose an item. Other: Click or tap here to enter text.
Behaviours of Concern/s	Choose an item. Other: Click or tap here to enter text.	Choose an item. Other: Click or tap here to enter text.	Choose an item. Other: Click or tap here to enter text.
Choose an item. Other: Click or tap here to enter text.	Choose an item. Other: Click or tap here to enter text.	Choose an item. Other: Click or tap here to enter text.
Implementing Provider Names	Click or tap here to enter text.	Click or tap here to enter text.	Click or tap here to enter text.	Click or tap here to enter text.
RP-3
Restrictive practice type	Choose an item.
Restrictive practice sup-type	Choose an item. Other: Click or tap here to enter text.
Behaviours of Concern/s	Choose an item. Other: Click or tap here to enter text.	Choose an item. Other: Click or tap here to enter text.	Choose an item. Other: Click or tap here to enter text.
Choose an item. Other: Click or tap here to enter text.	Choose an item. Other: Click or tap here to enter text.	Choose an item. Other: Click or tap here to enter text.
Implementing Provider Names	Click or tap here to enter text.	Click or tap here to enter text.	Click or tap here to enter text.	Click or tap here to enter text.
RP-4
Restrictive practice type	Choose an item.
Restrictive practice sup-type	Choose an item. Other: Click or tap here to enter text.
Behaviours of Concern/s	Choose an item. Other: Click or tap here to enter text.	Choose an item. Other: Click or tap here to enter text.	Choose an item. Other: Click or tap here to enter text.
Choose an item. Other: Click or tap here to enter text.	Choose an item. Other: Click or tap here to enter text.	Choose an item. Other: Click or tap here to enter text.
Implementing Provider Names	Click or tap here to enter text.	Click or tap here to enter text.	Click or tap here to enter text.	Click or tap here to enter text.
RP-5
Restrictive practice type	Choose an item.
Restrictive practice sup-type	Choose an item. Other: Click or tap here to enter text.
Behaviours of Concern/s	Choose an item. Other: Click or tap here to enter text.	Choose an item. Other: Click or tap here to enter text.	Choose an item. Other: Click or tap here to enter text.
Choose an item. Other: Click or tap here to enter text.	Choose an item. Other: Click or tap here to enter text.	Choose an item. Other: Click or tap here to enter text.
Implementing Provider Names	Click or tap here to enter text.	Click or tap here to enter text.	Click or tap here to enter text.	Click or tap here to enter text.
Declaration
I declare that: I understand that the NT Department of Health can be contacted at restrictive-practices.authorisation-unit@nt.gov.au I understand that I have a right to have access to the information contained within this Restrictive Practices – Application for Authorisation form. I acknowledge that the information contained in this Restrictive Practices – Application for Authorisation form has been collected for the purpose of making an authorisation decision (determination) in relation to the Application for Authorisation of Restrictive Practices. I consent to the Department of Health disclosing the information contained within this this Restrictive Practices - Application for Authorisation form to various persons or bodies, or classes of persons or bodies, including, but not limited to, the NDIS Quality and Safeguards Commission, NT statutory bodies, National Disability Insurance Agency, the NDIS participant and/or family/carers identified in this Restrictive Practices - Application for Authorisation form, internal Department of Health staff, other NT agencies and guardians or substitute decision makers; I consent to the Senior Practitioner conducting activity necessary as part of the authorisation process including seeking further information in relation to the authorisation application. I consent to the Senior Practitioner using any or all of the information contained within this Restrictive Practices - Application for Authorisation form and any subsequent information which may be obtained to make an authorisation determination. I consent to the Senior Practitioner using de-identified information contained within this Restrictive Practices - Application for Authorisation form for research, or the compilation or analysis of statistics. To the best of my knowledge, the information provided in this Restrictive Practices - Application for Authorisation form is true, correct and accurate. I acknowledge that it is an offence to provide false or misleading information to the NT Department of Health under the Act and under section 43BE of the Criminal Code Act 1983.
Signature
Full Name	Click or tap here to enter text.
Date	Click or tap to enter a date.
Job Title	Click or tap here to enter text.
Applicant NDIS Provider Details	Click or tap here to enter text.
Further information Email your completed form with attachments to restrictive-practices.authorisation-unit@nt.gov.au
End of form