Partners in Recovery ACT - Referral Form

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: pir@actml.com.au
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