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Home
Who We Are
Our Story
Our Approach
Our Clinicians
Our Management and Admin Team
Our Locations
Cultural and Community Mentoring Group
Careers and Pathways
First Nations Careers
What We Do
Psychology and Counselling Services
NDIS Services
Carer and Support Person Services
Commonwealth Psychosocial Support Program (CPSP)
Low Intensity Psychological Therapy (LIPT)
Professional Development
Staff Organisation Wellness and Enhancement Services
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
Step
1
of
2
50%
DETAILS OF REFERRAL
Referral Date
(Required)
Day
Month
Year
Consent for referral
(Required)
Client consent
Parent/Guardian/Carer consent (If aged 12-18)
This field is hidden when viewing the form
Referral Type
Select referral type
Workcover
Employee Assistance Program (EAP)
Self Referral
Other
This field is hidden when viewing the form
Service Location
Select location
Rockhampton
Thursday Island
Nambour
Other
This field is hidden when viewing the form
Other Referral Type
This field is hidden when viewing the form
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)
ELIGIBILITY CRITERIA
Consumer lives in Torres Strait?
(Required)
Yes
No
Consumer is over the age of 18?
(Required)
Yes
No
Consumer has severe mental health illness?
(Required)
Yes
No
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.
CONSUMER DETAILS
Name
(Required)
Preferred Name
D.O.B.
(Required)
Day
Month
Year
Gender
(Required)
Select
Female
Male
Prefer not to disclose
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
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
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
Select files
Accepted file types: jpg, pdf, docx, Max. file size: 50 MB.
For more information:
Freecall:
1800 732 850
Email:
referralsti@wakai-waian.com.au
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