Please complete this form and return it, along with a copy of the care plan, safety plan and/ or assessment summary (if available). A team member from The Way Back Support Service may follow up with you if more information is required to assess suitability or eligibility for the service. If they are deemed eligible, a Support Coordinator from The Way Back Support Service will contact the person being referred. Please ensure a consent form has been completed for each referral to avoid any delays.

To be eligible for The Way Back service, the consumer must meet the following criteria:

• Currently in hospital due to suicide attempt OR Currently in hospital due to Suicidal Crisis, experiencing distress, suicidal thoughts and articulating an intent to die.
• Is over 18 years old.
• Consented to this referral being made.
• Referred by Nepean Hospital PECC, TAC, Acute Unit or Older Persons Mental Health Unit, Safe Haven and ACCESS.
• Living in Penrith LGA.