Referral Intake Form

Fields marked * are required.

Website

Personal details

First name * Last name * Date of birth * Gender *

Male Not Specified Other

Email * Phone * Street address * Suburb / town * State * Postcode * Country Country of birth Is the person of Aboriginal origin?

Yes No

Is the person of Torres Strait Islander origin?

Yes No

Main language Dialect Is an interpreter required?

Yes No

Next of kin name Next of kin email Next of kin phone

Living arrangement

Current living arrangement * Who does the person live with?

Alone Family Share House

Is the house safe?

Yes No

Is the housing stable?

Yes No

Is the home safe and appropriate for a Case Worker to visit?

Yes No Unsure

Mental health

Does the person have a formal mental health diagnosis?

Yes No

Please describe the diagnosis

Please describe any mental health symptoms How long have the symptoms been present?

Physical health

Current physical health concerns Current medications, including dose Hospital admission in the last 30 days?

Yes No

Is a Community Treatment Order in place?

Yes No

Current treating doctor / team Treating doctor contact details

Substance use

History of alcohol or other drug issues *

Current Past No Issue

Further information on how substance use affects the person

Income and financial supports

Employment situation

Full Time Part Time Casual None

Connected with a Job Service Agency?

Yes No

Receiving Centrelink payments?

Yes No

Centrelink payment type

NDIS funding with a current plan?

Yes No

Further information on financial supports

Informal supports

Does the person have contact with family members?

Yes No

Any other informal support networks?

Yes No

Further information on informal supports

Safety

History of self-harm or harming others?

Yes No

History of suicide ideation?

Yes No

History of police contact?

Yes No

At risk of harm from others?

Yes No

History of being in custody?

Yes No

Further safety information

Referral agencies

If Pindari is not suitable, you may suggest up to two other agencies the person could be referred to. Both are optional.

Suggested agency 1 Agency 1 phone Agency 1 email Is the person eligible for agency 1?

Yes No Unsure

Primary reason for referral to agency 1 Services and support agency 1 would provide Suggested agency 2 Agency 2 phone Agency 2 email Is the person eligible for agency 2?

Yes No Unsure

Primary reason for referral to agency 2 Services and support agency 2 would provide

Confidentiality and Consent

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: * Applicant Name * Applicant E-Signature * Referring Staff Member * Referring Staff Member Email * Referring Agency * Date *