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Home
Who We Are
What We Do
News and resources
- News
- Videos
- Useful links
- Events
Referral Forms
Contact

WWH Commonwealth Psychosocial Support (CPSP) Referral Form

Fill in and submit the form below, or

Download a blank copy

This form is for people living in the Torres Strait who have a severe mental illness. If you live elsewhere or have a different condition, please complete the Consumer Referral Form instead.

Step 1 of 2

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This field is for validation purposes and should be left unchanged.

ELIGIBILITY CRITERIA

If you select No to the first 2 questions, please complete our Consumer Referral Form.

Consumer lives in Torres Strait?(Required)

Yes

No

Consumer has severe mental health illness?(Required)

Yes

No

Consumer is over the age of 18?(Required)

Yes

No

If you don't reside in the Torres Strait please complete our Consumer Referral Form.

If you don't have a severe mental illness, please use the Consumer Referral Form.

Diagnosis/Disability?

Consumer requires support in one or more areas to build capacity and stability:(Required)

Social skills and friendships

Family connections

Managing daily living needs

Financial management and budgeting

Finding and maintaining a home

Vocational skills and goals, including volunteering

Educational and training goals

Maintaining physical wellbeing, including exercise

Managing drug and alcohol addictions, including tobacco

Building broader life skills including confidence and resilience.

DETAILS OF REFERRAL

Referral Date(Required)

Day

Month

Year

Consent for referral(Required)

Client consent

Parent/Guardian/Carer consent (If aged 12-18)

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Referral Type

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Service Location

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Other Referral Type

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Other Service Location

REFERRER

Name of referrer(Required)

Organisation(Required)

Referrer position/profession(Required)

Provider number (if applicable)

Referrer phone number(Required)

Referrer email(Required)

Referrer address(Required)

CONSUMER DETAILS

Name(Required)

Preferred Name

D.O.B.(Required)

Day

Month

Year

Gender(Required)

Cultural heritage(Required)

Aboriginal

Torres Strait Islander

Both

Neither

Culturally & Linguistically Diverse Background

Address

Experiencing

homelessness

Email

Phone numbers

Parent/Carer/Guardian Name (if aged 12-18)

Relationship

ADDITIONAL INFORMATION

Reason for referral(Required)

Consumers goals and hopes

Medication details (if applicable)

Outcomes/scores of any relevant psychosocial assessments (e.g. K5, K10, SDQ)

Risks of harm to self

Self harming

Increased risk of suicide

Other

Other risks of harm to self

*If assessed at high risk of suicide please contact Emergency Services on 000 or Mental Health Service Acute Care Team

Other services the consumer is accessing

Other relevant information/reports

(List here or upload below)

Are there any risk factors we should be aware of?

(List here or upload risk assesment below)

HOME VISIT RISK ASSESSMENT

If any risks are identified, further assessment will be conducted prior to the home visit.

Does the consumer live alone?(Required)

Yes

No

If No, is it safe to enter the home?(Required)

Yes

No

Are there any aggressive animals?(Required)

Yes

No

Is there any clutter or tripping hazards?(Required)

Yes

No

Does anyone at the home have a history of violence?(Required)

Yes

No

Does anyone at the home have any substance abuse?(Required)

Yes

No

Are there firearms in the home?(Required)

Yes

No

Does anyone at home have an infectious disease?(Required)

Yes

No

Is there mobile phone service at the home?(Required)

Yes

No

Will there be anyone else present at the home at the time of the support? (If yes, please provide details)(Required)

Yes

No

Details of others likely to be present at time of support visit(Required)

Are there any other risks that affect the clinician safety and wellbeing by accessing the home?(Required)

Yes

No

List risks to clinician safety and wellbeing in the home(Required)

Is there a space for the clinician and consumer to meet privately?(Required)

Yes

No

Are there any risks that affect the clinician safety and wellbeing when assisting in the community?(Required)

Yes

No

List risks to clinician safety and wellbeing in the community(Required)

CONSUMER PREFERENCES

Preferred gender of worker(Required)

Female

Male

No preference

Preferred contact method/s(Required)

Mobile

Home phone

Email

via Referrer

Home visit

Other

Other preferred contact method

Ok to leave voicemail/send SMS?

Voicemail

SMS

Either

Ok to leave letter/card at home?

Yes

No

Upload Mental Health Care Plan and relevant documents (ie. Risk Assessment)

Drop files here or

Accepted file types: jpg, pdf, docx, Max. file size: 50 MB.

For more information:

Freecall: 1800 732 850
Email: referralsti@wakai-waian.com.au

Wakai Waian Healing acknowledges the Elders and Traditional Owners in those regions where our staff operate. We acknowledge Aboriginal and Torres Strait Islander people’s unique lived experiences, cultures, countries, nations, customs, and traditions.

Wakai Waian Healing is a 100% Indigenous Owned Organisation registered with Supply Nation.

Our Services & Priorities

Psychology and Counselling Service
NDIS Services
Low Intensity Psychological Therapy (LIPT)
Commonwealth Psychosocial Support Program (CPSP)
Carer and Support Person Services
Community Capacity Building

Psychology and Counselling Service
NDIS Services
Low Intensity Psychological Therapy (LIPT)
Commonwealth Psychosocial Support Program (CPSP)
Carer and Support Person Services
Community Capacity Building

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Locations

ROCKHAMPTON
104 Fitzroy Street
Rockhampton QLD 4700

NAMBOUR
Suite 1, 80 Blackall Terrace
Nambour QLD 4560

THURSDAY ISLAND
40 Douglas Street
Thursday Island QLD 4875

Additional locations

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