Referral Date ___/___/___

Please contact ACSO Connectph. 5172 2900 or 1300 022 760,emailto make a referral.

Referrers should keep in mind that PIR is a highly targeted program aiming to assist a group of people with severe and persistent mental illness who have the highest levels of disability and complexity of need.

This program is funded by DoH and will be transitioning to the NDIS in June 2019.

Personal details:
Name:______Preferred Name:______
DOB:______Sex :  Male  Female  Transgender  Intersex Other
Are you of Aboriginal or Torres Strait Islander origin? Yes, Aboriginal Yes, both Aboriginal & Torres Strait Islander
Yes, Torres Strait Islander Neither Aboriginal, nor Torres Strait Islander
Prefer not to say
Address:______
Phone:______Mobile:______
Email:______
Is English your first language? Yes No If No, do you require an interpreter? Yes No
Language:______
Are you a National Disability Insurance Scheme (NDIS) participant? YesNo
Do you have any current legal involvement? Yes No
If yes, please provide relevant detail:
Order type: ______Expiry of order: ______
Support Officer/Agency: ______
If there is current legal involvement, please first seek further advice from intake to ensure referral appropriateness.

Eligibility requirements for acceptance into PIR

Please respond directly to the below eligibility criteria as outlined:

  1. The person has or appears to have a severe and complex mental illness that is persistent in duration.

In assessing this, the referrer should provide evidence of the following:

  • Evidence of severity can include:

-A reported diagnosis of psychotic illness; or

-A reported diagnosis of another mental illness with associated impairment across a range of functioning domains; or

-The person has experienced multiple hospitalisations for treatment of mental illness over the past 3 years; or

  • Evidence of persistent mental illness can include:

-The person is a recipient of the Disability Support Pension where mental illness is the principal condition; or

-The person has experienced mental illness over many years, or is likely to do so; or

-The person has recently experienced the onset of a mental illness that is expected to be of a prolonged nature (lasting years, not months).

______

  1. The person has complex needs that require services from multiple agencies.

Are services currently in place, pending referral or require referral and is client agreeable to receive this support.

______

  1. The person requires substantial support and assistance to engage with the various services to meet their needs.

Provide evidence on how and/or why the client has been unable to achieve this in the past.

______

  1. Please list any organisations that the person is supported by:

ORGANISATION / CLINICIAN NAME / ROLE / CONTACT #

Please ensure there are no existing coordination arrangements in place to assist the person in accessing the necessary services, or where they are in place, those arrangements have failed, have contributed to the problems experienced by the client, and are likely to be addressed by acceptance into PIR.

______

  1. Risk Information:

Provide information about current and/or potential risk to self & others, including alerts for staff e.g. forensic history or aggressive behaviour.

______

  1. The person or their legal guardian has given their consent to being involved, and is willing to participatein PIR. See next page

Additional comments:

Does the person meet the eligibility requirements of PIR? Yes No

Partners in Recovery

Consent Form

Consumer Privacy

You have been referred to the Partners in Recovery Initiative. Participation in this program will require the referrer to provide some information about you, including your name, date of birth and why you are seeking support to the Support Facilitator Organisation.

Some of your personal information collected in the referral form will be recorded by Gippsland PHN. Gippsland PHN is committed to providing you with the highest level of confidentiality and customer service whilst facilitating referral information. This includes protecting your privacy. Gippsland PHN will manage your information in accordance with the Commonwealth Privacy Act 1988 and the Australian Privacy Principles (APPs). All information collected about you is confidential and will be stored securely in a locked place. At any time you may request to see information held about you. You also may withdraw from the initiative at any time.

Non identifying information will be provided to the Australian Government Department of Health for future planning and funding purposes.

If you agree to this referral, please complete and sign the consumer consent section below.

Consumer Consent

Written consumer consent
I agree that information about my mental health and wellbeing may be collected, used and disclosed to the Support Facilitation Organisation to whom I am referred, where this is required to assist in the management of my health care.
I agree that information (that will not identify me to any external parties) is being collected and used to assist in improving the Partners in Recovery Initiative, and I agree to this de-identified information being collected and shared.

Consumer Name Consumer Signature Date

Referrer Consent

I have discussed the proposed referral to a Support Facilitation Organisation with the consumer and/or carer and am satisfied that the consumer and/or carer understands the proposed collection, use and disclosure of personal health information and has provided informed consent to the proposed collection, use and disclosure.
Referrer Name Referrer Signature Date

Last modified 30/01/2018 Page 1 of 3