ChecklistTick box
1Personal Profile / contact details of person to which the Restrictive Intervention applies 
2Have you discussed with client's Nominated Person (e.g. family member, Advocate). 
3Brief 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?). 
4Description of Restrictive Intervention (e.g. Indicate if this practice is Environmental or Personal). 
5Description of impact of Restrictive Intervention on others 

Evidence supporting application:

  • Allied Health Professional Reports
  • GP report
  • Behaviour Intervention Plan
  • Specialist reports
  • Person responsible opinion
7Alternative interventions trailed (e.g. different clothing; avoiding situations; distraction; staff education and training). 
8Results of trials i.e. - worked/didn't work - inks to point seven. 
9Protocol for use of Restrictive Intervention - (see example in package) 
10Evidence of staff knowledge and understanding of protocol. 
11Options 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. 

Are similar interventions in place for the client in other services accessed by the client – include relevant information.