Referral Intake Form

Personal Details

Name(Required)

First Last

Date of Birth(Required)

Day

Month

Year

Gender(Required)

Male

Not Specified

Other

Email(Required)

Phone(Required)

Current Living Address(Required)

Street Address City State / Province / Region ZIP / Postal Code Country

Country of Birth

Are you of Aboriginal origin?

Yes

Are you of Torres Strait Islander origin?

Yes

Main Language

Dialect

Do you require an interpreter?

Yes

Next of Kin

Next of Kin Name

First Last

Next of Kin Email

Next of Kin Phone

Confidentiality and Consent(Required)

I agree to the Pindari House Privacy Statement

Please read this form through with the person and take the time necessary to help them understand what confidentiality and informed consent is.

Privacy Statement
All necessary steps are taken to ensure that the privacy and confidentiality of all information gathered during your support period with Pindari House. Case notes are completed following the completion of each meeting you attend with Pindari House and stored in person files in accordance with the Privacy Act 1988.

Confidential information will only be disclosed in the following circumstances:
1. If you have provided written consent (Permission to Release Personal Information Form) for information to be shared between Pindari House and another party.
2. For Professional Supervision purposes with another allied Health Professional. Your personal information remains anonymous to protect your privacy and confidentiality.
3. If the Courts subpoena (instructs) Pindari House to provide information.
4. If you, a child in your care or another person is considered to be at serious risk of harm which warrants disclosure of information.

I have had the following explained to me and understand:(Required)

There are some circumstances where Pindari House may have to break confidentiality to keep me safe

This is a voluntary service, and I can choose to end my support period with Pindari House at any time

If I have any questions or concerns about the service and support, I receive from Pindari House, I can discuss this with my Case Manager

Applicant Name(Required)

First Last

Applicant E-Signature(Required)

First

Referring Staff Member(Required)

First Last

Referring Staff Member Email(Required)

Date(Required)

Day

Month

Year

Living Arrangement

What best describes your current living arrangement?

Caravan Park

Home Owner

Private Rental

Public Housing

Sleeping Rough

Couch Surfing

Hospital

Crisis Accomodation

Temporary Housing

Transitional Housing

Prison

Other Homelessness

Who do you live with?

Alone

Family

Share House

Is the house safe?

Yes

Is the house stable?

Yes

Is it safe and appropriate to send a Case Worker to the property?

Yes

Unsure

Mental Health

Do you have a formal mental health diagnosis?

Yes

What is your mental health diagnosis?

Please describe your mental health symptoms

How long have you been experiencing mental health symptoms?

Physical Health

What are your current physical health concerns?

Please list your current medications (including dose)

Have you had a hospital admission in the last 30 days?

Yes

Is there a Community Treatment Order in Place?

Yes

Existing Medical Supports

Current Treating Doctor or Team

Treating Doctor Contact Details

Substance Use

Have you had any issues with Alcohol and/or other Drugs?

Current

Past

No Issue

Please provide further information if this affects the support required:

Income and Financial Supports

What is your current employment situation?

Full Time

Part Time

Casual

None

Are you connected to a Job Service Agency?

Yes

Do you receive Centrelink payments?

Yes

Centrelink Payment Type:

Do you receive NDIS funding with a current plan?

Yes

Please provide further information in relation financial supports:

Informal Supports

Do you have contact with any family members?

Yes

Do you have other informal support networks?

Yes

Please provide further information in relation to informal supports:

Safety

Do you have a history of harming yourself and/or others?

Yes

Do you have a history of suicide ideation?

Yes

Have you ever been in trouble with the Police?

Yes

Are you at risk of harm from someone else?

Yes

Have you ever spent time in custody?

Yes

Please provide any further information in relation to safety:

Referral Agency 1

Suggested Agency for Referral

Phone

Is the person eligible?

Yes

Primary reason for referral:

What can this referral agency provide in terms of services and support for this person?

Referral Agency 2

Suggested Agency for Referral

Phone

Is the person eligible?

Yes

Primary reason for referral:

What can this referral agency provide in terms of services and support for this person?

CAPTCHA

Personal Details

Next of Kin

Living Arrangement

Mental Health

Physical Health

Existing Medical Supports

Substance Use

Income and Financial Supports

Informal Supports

Safety

Referral Agency 1

Referral Agency 2

Are you ready to turn your life around and break the chains of addiction ?

The Program

Support Us