Community Connections Program

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Community Connections Program

Referral Form

STRICTLY CONFIDENTIAL

279 High Street,
Northcote VIC 3070
Phone: 9482 3488
Fax: 9482 3119
Email:
FOR OFFICE USE ONLY
Date referral received:______
Referral taken by: ______
Initial contact made on & by whom: ______
Date of assessment meeting: ______

Referring Agency Details

Referring Agency: ______
Referring Worker : ______
Phone: (_____)______
Fax: (_____)______
Date of Referral: ______
I have spoken to a staff member in the Community Connections Program to confirm the applicant meets the eligibility criteria? Yes No
What is your role with the applicant?
______
______
______
______
Has the applicant given written consent for this referral? Yes No
Please gain written or verbal consent before proceeding.

Applicant Details

Name of Applicant ______
Contact Address(for correspondence, home visits etc):

Contact phone number/s

(Indicate preferred number)
Home: (_____)______
Mobile: (_____)______
Email: ______
What is the applicant’s date of birth? dd/mm/yyyy ____/____/______
What is the gender of the applicant? Male Female
Income type:______CRN (if available):______
Treating Doctor:______Telephone:______
Doctor’s address:______
Next of Kin:______
Relationship to client:______
Telephone:______
Cultural Identity/Religion:______
Indigenous/Torres Strait Islander? Yes No
Main Language Spoken:______
Do you require an Interpreter? Yes No
What other cultural or language barriers need to be considered in delivering services to the applicant?
Ie- poor literacy, impaired hearing or vision, cultural needs or behaviours.
Please specify:
______
______
______
If relevant please note disability type – (i.e. ABI, Intellectual, Physical or Psychiatric)
______

Support Details

Does the applicant have a carer/advocate? Yes No
If yes, please provide carers/advocate name, relationship to client and contact details:
______
______
______
Does the applicant have a Case Manager? Yes No
If yes, please provide agency and case manager’s contact details:
______
______
______
Doe the applicant have any other services/agencies involved? Yes No
If yes, please provide their contact details and details regarding the support provided:
______
______
______
______
______
Does the applicant manage his or her own finances? Yes No
If no please provide details of the administrator:
______
______
______
Does the applicant have any dependants or other family members living with them? Yes No
Please provide details:______
______
______

Housing Information

What is the applicant’s residential setting?

Private rental
Privately owned property

Office Housing property
Supported Residential Service

Residential mental health service
Boarding house/private hotel
Psychiatric or acute care hospital

Public place/temporary shelter/homeless/couch surfing
Specialised alcohol or drug treatment
Caravan
Other, please specify
Is the applicant homeless?
Yes
No
Is the applicant at risk of homelessness?
Yes
No
Please provide details:
______
______
______
______
Medical Information
Does your applicant have unmet health needs? Yes No
Provide details:
______
______
______
______
How does this impact on their capacity to maintain their independence?
______
______
______
______
Is the applicant able to self-administertheir medication? Yes No
If no, please provide details of how this is addressed:
______
______

Mental Health Information

Does this applicant have any mental health issues? Yes No
If so please specify:
______
______
______
______
Who is the applicantbeing treated/supported by for their mental health?
General Practitioner Contact Details:______

Psychiatrist ______

Specialist mental health service ______
Clinical psychologist ______

None

Alcohol/Drugs Information

Does the applicant have current or past drug and alcohol issues? Yes No

If yes, please specify:
______
______
______
Is the applicant willing to address issues related to their alcohol or other drug use?
Yes No

Legal Information

Does the applicant have any legal matters pending? Yes No
If yes, please specify:
______
______
______
______

Risk Assessment

Can you identify any concerns or risks to our staff when working with this applicant or visiting their home?
i.e. – behaviours of concern, other residents, pets, squalor, drug and alcohol issues etc.
Yes No
If yes, please specify:
______
______
______
______
Referrer’s Signature: ______Date: ____/___/______