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Referral form

Family, Friends and Kin Support Program

This form is for referral partners only

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All are welcome

To be eligible for Family, Friends and Kin service, the consumer must meet the following criteria:

Referral Criteria:

  • The Carer must be 18 years of age or older.
  • Caring/supporting someone who has or is experiencing a suicidal crisis or following a suicide attempt
  • Living in one of the following Local Government Areas: Maranoa Regional, Balonne Shire, Paroo Shire, Murweh Shire, Quilpie Shire, or Bulloo Shire

Service Delivery Note: Face-to-face support is available for carers in the Maranoa Regional (office based in Roma) and Balonne Shire (office based in St George) regions. For carers in the Paroo, Murweh, Bulloo and Quilpie Shire regions, support will be delivered via telehealth.

Family, Friends and Kin Support Program – Referral Form

Please complete this form if you are interested in accessing support from the Family Friends & Kin support service.

"*" indicates required fields

Referrer Information

Carer Information

Gender*
Relationship status:*

Do you identify as:*
Relationship to person being supported (If known)*
Who is the person you are caring for who is experiencing suicidal distress?
Has the Client consented to be contacted?

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