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Referral Form

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

Referral Date: Referral Type:

This is an enquiry for me This is a Referral for someone else in my care

Participant Information:

First Name: Surname: Contact Number: Email: Postcode: Gender: Please Specify Self Identity:

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

Referrer Information:

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

NDIS Services: Does the participant have an NDIS plan?

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

Support Requirements:

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?

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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