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Referral Form

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Use this form to enquire about yourself or someone in your care to our services. We’ll get back to you as soon as possible.

* These fields are required to complete your request.

Enquiry Date: Enquiry Type:

This is an enquiry for me This is for someone in my care.

Enter the details of the person:

First Name*: Surname*: Email address*: We use this to confirm we have received your expression of interest Contact number*: Your phone number will be kept confidential and not shared with others. Postcode*: Gender: Please Specify Self Identity:

Age Group*:

Does the Participant identify as:

Aboriginal or Torres Strait Islander LGBTQI

Is the Participant:

From a home where English is not their first language Aged 0 to 11 years with, or at risk of developing, mental illness or behavioural issues Living in a rural / remote community

Your Information:

Relationship to the Participant: Main Point of Contact*: Organisation*: Position Title: First Name*: Surname*: Referrer Contact Number: Email address*:

Do you have a current National Disability Insurance Scheme (NDIS) plan?*

Please tick at least box.

Yes

No

I’m not sure

NDIS details: Reference Number: Plan start date: Plan review date: Budget: Plan managed by:

Support Requirements*:

Please tick at least box.

Assistance with daily life tasks Community access Group activities in a centre Group activities in the community Support coordination Capacity building for an individual Capacity building in a group Therapy/counselling Behaviour support plan implementation Finding a residence Other support requirements Please specify:

Is the Participant experiencing, or at risk of any of the following?*

Please tick at least box.

Suicide or self-harm Criminal offence Perinatal depression or anxiety Financial disadvantage or hardship Depression Sexuality/sexual identity Psychoses or delusions Sexual assault Disordered eating/body image Homelessness Domestic and family violence Anxiety Behavioural issues Alcohol or substance abuse Seeking asylum or refugee status Other trauma Please specify:

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We acknowledge the Traditional Custodians of the land on which we live and work, and of the many different nations across the wider regions from which we all come. We pay our respects to the Elders, past, present and emerging as the holders of the memories, the traditions, the culture and the spiritual wellbeing of the Aboriginal and Torres Strait Islander peoples across the nation. We acknowledge any Sorry Business that may be affecting the communities as a whole.

Read our Reconciliation Action Plan to learn more about our Reconciliation journey.

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