Referral Date Partners in Recovery ACT - Referral Form Please fill in ALL details at points 1, 2, 3 and 4 to avoid delays in this referral being progressed. 1. Participant Details Family Name: Given Names: Gender: Female □ Male □ Not Specified □ Date of Birth: Phone: Physical Address: Mailing Address: Email: Is the Participant registered with NDIS? Yes □ No □ Unknown □ 2. Participant Service Preferences* Male □ Support Facilitator gender preference: Female □ No Preference □ Would the participant prefer to work with a Support facilitator that identifies as Aboriginal or Torres Strait Islander? Yes □ No □ No Preference □ Does the participant need access to an interpreter? Yes □ No □ Unknown □ If Yes, Which language____________________________ Preferred service provider? Anglicare □ CatholicCare □ Mental Illness Fellowship of Victoria □ Northside Community Service □ Richmond Fellowship of ACT □ Woden Community Service □ No Preference □ *Every effort will be made to meet these preferences; however program capacity may influence the outcome. 3. Referral Completed By Participant Above □ (No need to complete this section if participant, go to point 4) Family Member □ Relationship to individual ___________________ Name of Referrer: __________________________ Phone: ____________________ Email: ____________________ Service Provider/Staff Member □ Service Name______________________ Service Type_______________________ 4. Eligibility Criteria 1. The participant experiences severe and persistent mental health concerns and/or has a diagnosis? Yes □ No □ Unknown □ 2. The participant has complex needs that require services from multiple agencies, and requires support to engage with these services? Yes □ No □ Unknown □ 3. The participant is engaged with services, but could benefit from greater coordination and continuity of care? Yes □ No □ Unknown □ 4. The individual has been informed about the program, has consented to this referral, and is willing to engage in this program? Yes □ No □ Unknown □ www.actml.com.au/programs/partners-in-recovery Referral Form v 2.0 25/07/2014 Online Referrals can be made at: https://pirforms.actml.com.au Page 1 of 3 Partners in Recovery ACT – Further Participant Information These additional pages can be completed by the participant, or referrer, to supply additional information. Completing these sections will help the individual not to repeat their information again to another service provider. Country of Origin Current Mental Health Support Country of birth: ☐ Public sector mental health service Main language spoken at home: ☐ Community Mental Health Yes ☐ Refugee status: No ☐ Unknown ☐ Service contact: If yes, year of arrival: Service Name: Aboriginal or Torres Strait Islander Status Address: ☐ Aboriginal but not Torres Strait Islander origin ☐ Torres Strait Islander but not Aboriginal origin Phone: ☐ Both Aboriginal and Torres Strait Islander origin Are you currently accessing any other services? ☐ Neither Aboriginal or Torres Strait Islander origin Service Name/Type: ☐ Origin not stated or inadequately described Service contact: Marital Status Address: ☐ Married (registered and de facto) ☐ Never Married ☐ Separated ☐ Divorced ☐ Widowed ☐ Not Disclosed Phone: Current Education Service Name/Type: ☐ Secondary School Service contact: ☐ TAFE/Technical/Vocational/RTO Address: ☐ University/other Higher Education ☐ Other Courses; adult education, hobby courses Phone: ☐ N/A Court and Statutory Orders ☐ Not known ☐ Mental health orders Employment Participation (please tick one): ☐ Orders relating to children ☐ Full-time ☐ Intervention orders ☐ Part-time/Casual ☐ Unemployed (but actively looking for work) ☐ Guardianship and administration orders ☐ Not in the labor force ☐ Other ____________________________ www.actml.com.au/programs/partners-in-recovery Referral Form v 2.0 25/07/2014 Online Referrals can be made at: https://pirforms.actml.com.au ☐ N/A Page 2 of 3 Partners in Recovery ACT – Further Participant Information Presenting issue(s) and Reason for referral to PIR Mental Health Diagnosis/History: There are concerns about the participants’ capacity to make decisions? Yes □ No □ If Yes, Please provide further comment: _______________________________________________________________________________________________________ _______________________________________________________________________________________________________ Are there any risk related behavior/s that this participant has engaged with in the past 6 months: Harm towards self □ Harm towards others □ Unknown □ Please provider further comment: _______________________________________________________________________________________________________ _______________________________________________________________________________________________________ Further Participant Information completed by (if not referred participant): Name: Service name: Signature: Address: Email: Date: Contact Number: This Referral is Now Complete. Please forward completed referral to Partners in Recovery Intake: Phone: 02 6287 8070 Fax: 02 6100 9960 Mail: PO Box 9, Deakin West, ACT 2600 Email: [email protected] www.actml.com.au/programs/partners-in-recovery Referral Form v 2.0 25/07/2014 Online Referrals can be made at: https://pirforms.actml.com.au Page 3 of 3