Updated: July 2020 Page 1 of 6 Form ID: CC026

This Referral Form is for St Bart’s Integrated Services. It should be completed with the applicants consent and, ideally, in the presence of. Please ensure all sections are completed, with the relevant supporting documents attached, before sending it to the Intake and Admissions Coordinator at intake@stbarts.org.au. Please note incomplete or illegible referrals will be returned, resulting in processing delays. Referrals will also be deemed incomplete until all of the applicable information has been received.

REFERRER DETAILS Referrers name: Date of referral: / /

Organisation: Position:

Email: Phone:

ST BART’S INTEGRATED SERVICES Which service/s are you applying for (tick all that apply):

☐ Future Homes [FH] Men’s Service ☐ Kensington Street [KS] Women’s Service ☐ Bart’s Plus [B+] Family Service ☐ Arnott Community Recovery Village [ACRV] ☐ Bentley Community Recovery Village [BCRV] ☐ Sunflower Community Recovery Village [SCRV] ☐ Swan Community Recovery Village [SwCRV] ☐ Cannington Accommodation Unit [CAU] ☐ Medina Accommodation Unit [MeAU] ☐ Midland Accommodation Unit [MiAU]

For all enquiries, please contact the Integrated Services Intake and Admissions Coordinator at intake@stbarts.org.au or call (08) 9323 5124.

SUPPORTING DOCUMENTS

Please include the following information with your referral (if applicable): ☐ Primary diagnosis of a Mental Health disorder* ☐ Current Mental Health Care Plan (if applicable) ☐ Client Management Plan (including PSOLIS alerts)* ☐ Current National Disability Insurance Scheme [NDIS] Plan (if applicable) ☐ Brief Risk Assessment completed by a clinician* ☐ Recent Discharge Summaries (if applicable) ☐ Medication regimen or Community Treatment Order [CTO]* ☐ Physical Health Assessment completed by a Doctor / General Practitioner* ☐ Forensic history including any current legal issues (e.g. orders, upcoming court dates)

* These documents are mandatory if you are applying for a Community Recovery Village or Accommodation Unit.

REFERRAL FORM REFERRAL FORM - Integrated Services

mailto:intake@stbarts.org.aumailto:intake@stbarts.org.au

Updated: July 2020 Page 2 of 6 Form ID: CC026

APPLICANT DETAILS First name: Surname:

Preferred name: Date of birth: / /

Current address:

Suburb: Postcode:

Email: Phone:

Gender: ☐ Male ☐ Female ☐ Transgender Male ☐ Transgender Female ☐ Non-binary Do you identify as LGBTI: ☐ Yes ☐ No ☐ Unsure ☐ Prefer not to say Aboriginal or Torres Strait Islander: ☐ Yes ☐ No ☐ Prefer not to say Culturally and Linguistically Diverse: ☐ Yes ☐ No ☐ Prefer not to say Main language spoken: ☐ English ☐ Other: ______________ Country of Birth: Interpreter required: ☐ Yes ☐ No Visa status: Marital status: ☐ Single ☐ De facto ☐ Divorced ☐ Married ☐ Separated ☐ Widowed Children: ☐ Yes ☐ No

If applying for Bart’s Plus Family Service, please answer these questions:

Who else will be living with you:

Full name: Date of Birth: Gender: Relationship:

Full name: Date of Birth: Gender: Relationship:

Full name: Date of Birth: Gender: Relationship:

Do they have any health issues: ☐ Yes ☐ No More information:

Do they require any support: ☐ Yes ☐ No More information:

Are the children attending school: ☐ Yes ☐ No More information: Are there custody issues: ☐ Yes ☐ No Do you have primary custody: ☐ Yes ☐ No Is the Department for Child Protection and Family Support [DCPFS] involved: ☐ Yes ☐ No More information:

FINANCE Source of income: ☐ Age Pension ☐ Youth Allowance ☐ Disability Support Pension ☐ Paid Work ☐ Newstart Allowance / JobSeeker ☐ Other: __________________ Do you currently have any outgoings (e.g. Fines, child support etc.):

Do you hold a Department of Veterans’ Affairs [DVA] Health Card: ☐ Yes ☐ No

Updated: July 2020 Page 3 of 6 Form ID: CC026

Centrelink Customer Reference Number [CRN]: Expiry:

Medicare number: Expiry:

HOUSING Have you stayed at St Bart’s before: ☐ Yes ☐ No If yes, when: Housing history:

Current living situation: ☐ Privately owned ☐ With friends ☐ Hospital ☐ Rental ☐ Supported ☐ Homeless ☐ With carer / family ☐ Hostel ☐ Other: ___________ Are you on the Housing waitlist: ☐ Yes ☐ No Are you priority listed: ☐ Yes ☐ No

CONTACTS Next of Kin or nominated support person: Relationship:

Email: Phone:

Do you have a Clinical Case Manager: ☐ Yes ☐ No Name: Email: Phone:

Do you have a Doctor / General Practitioner [GP]: ☐ Yes ☐ No Name: Email: Phone:

Do you have a Psychiatrist: ☐ Yes ☐ No Name: Email: Phone:

Do you have a Guardian: ☐ Yes ☐ No Name: Email: Phone:

Do you have a Public Trustee: ☐ Yes ☐ No Name: Email: Phone:

Do you have a Carer: ☐ Yes ☐ No Name: Email: Phone:

Is this Carer a child or aged person: ☐ Child ☐ Aged person ☐ Other: _____________________ Do you have a DCPFS Case Worker: ☐ Yes ☐ No Name: Email: Phone:

Branch:

Do you have a Communuty Corrections Officer: ☐ Yes ☐ No Name: Email: Phone:

Location:

Other Support Person / Service (e.g. NDIS, Silverchain etc.): Name:

Email: Phone:

Updated: July 2020 Page 4 of 6 Form ID: CC026

DISABILITY If you have a Disability, please specify: ☐ N/A Do you have a current NDIS Plan: ☐ Yes ☐ No If yes, please include a copy with this referral.

Do you have any current support from a Disability service (e.g. Silverchain etc.): ☐ Yes ☐ No Details:

PHYSICAL HEALTH Physical Health issues / conditions (tick all that apply):

Diabetes ☐ Yes ☐ No Falls risk ☐ Yes ☐ No Heart complaint ☐ Yes ☐ No Respiratory disease ☐ Yes ☐ No

Liver disease ☐ Yes ☐ No Bruise or bleed easily ☐ Yes ☐ No Epilepsy ☐ Yes ☐ No Skin conditions ☐ Yes ☐ No

HIV / AIDS ☐ Yes ☐ No Stomach conditions ☐ Yes ☐ No Hepatitis A ☐ Yes ☐ No Asthma ☐ Yes ☐ No Hepatitis B ☐ Yes ☐ No Allergy (medically diagnosed) ☐ Yes ☐ No Hepatitis C ☐ Yes ☐ No Anaphylatic ☐ Yes ☐ No Hepatitis D ☐ Yes ☐ No Medication allergy ☐ Yes ☐ No

Low blood pressure ☐ Yes ☐ No Pregnant ☐ Yes ☐ No High blood pressure ☐ Yes ☐ No Acquired Brain Injury ☐ Yes ☐ No Speech impairment ☐ Yes ☐ No Thyroid problem ☐ Yes ☐ No

Visual impairment ☐ Yes ☐ No Eating disorder ☐ Yes ☐ No Hearing impairment ☐ Yes ☐ No Other: ____________________. ☐ Yes ☐ No Mobility impairment ☐ Yes ☐ No Other: ____________________. ☐ Yes ☐ No

Substance use (if yes, please include details under ‘Drug and Alcohol Use’) ☐ Yes ☐ No If you ticked yes to any of the above, please provide details:

MENTAL HEALTH If you have a Mental Health diagnosis, please specify: ☐ N/A

Are you under the care of a Community Mental Health Service: ☐ Yes ☐ No If you ticked yes, please specify which area / team:

Updated: July 2020 Page 5 of 6 Form ID: CC026

MEDICATION Do you take regular prescribed medication: ☐ Yes ☐ No Is it Webster packed: ☐ Yes ☐ No Do you require support taking your medication: ☐ Yes ☐ No Are you on a Community Treatment Order [CTO]: ☐ Yes ☐ No Any hospital admissions in the last 12 months: ☐ Yes ☐ No If yes, please provide details:

DRUG AND ALCOHOL USE Do you have a history or are you currently using drugs or alcohol: ☐ Yes ☐ No If yes, please provide details of drug(s) of concern, frequency, amount, history of use:

Are you currently smoking tobaacco: ☐ Yes ☐ No If yes, please provide details of frequency and amount:

Are there any associated risk behaviours or problems (e.g. Hepatisis, injecting, overdose): ☐ Yes ☐ No If yes, please provide details:

Are you currently accessing support around your smoking, drug or alcohol use: ☐ Yes ☐ No If yes, please provide details:

LEGAL / OFFENCES Do you have any past or current legal issues (e.g. Community orders / pending court dates / prison history): ☐ Yes ☐ No If yes, please provide details:

If being referred from prison, please answer these questions:

Prison location: Time length in prison:

Full sentence date:

Are you applying for Parole: ☐ Yes ☐ No If yes, Parole date: Have you been assigned a Community Corrections Officer: ☐ Yes ☐ No If yes, please include details under ‘Contacts’.

Updated: July 2020 Page 6 of 6 Form ID: CC026

SUPPORT NEEDS Are there any particular tasks you find challenging:

What support do you need (tick all that apply):

☐ Toileting ☐ Gardening ☐ Medication ☐ Showering ☐ Transport ☐ Advocacy ☐ Dressing / undressing ☐ Shopping ☐ Accessing services ☐ Clothes washing ☐ Budgeting ☐ Attending appointments ☐ Cleaning ☐ Staying safe ☐ Engaging with social groups ☐ Cooking ☐ Communicating (reading / writing) ☐ Family relationships ☐ Eating ☐ Computer / IT skills ☐ .Getting in / out of bed ☐ Other: _________________ ☐ Other: _________________ ☐ Other: _________________ Do you get support from other services: ☐ Yes ☐ No If yes, please include details under ‘Contacts’.

OTHER Additional comments:

☐ I acknowledge the information provided is correct and true. ☐ I agree that St Bart’s may contact my health / community service providers to gather

additional information to assist with my referral, if needed. ☐ I consent to my referral being submitted for consideration of the selected St Bart’s

Integrated Services. Applicant name: ______________________________ Date: ____/____/______ Signature: ______________________________ If the applicant has a state appointed Guardian, they must additionally sign: Guardian name: ______________________________ Date: ____/____/______ Signature: ______________________________

Future Homes FH Mens Service: OffKensington Street KS Womens Service: OffBarts Plus B Family Service: OffArnott Community Recovery Village ACRV: OffBentley Community Recovery Village BCRV: OffSunflower Community Recovery Village SCRV: OffSwan Community Recovery Village SwCRV: OffCannington Accommodation Unit CAU: OffMedina Accommodation Unit MeAU: OffMidland Accommodation Unit MiAU: OffPrimary diagnosis of a Mental Health disorder: OffCurrent Mental Health Care Plan if applicable: OffClient Management Plan including PSOLIS alerts: OffCurrent National Disability Insurance Scheme NDIS Plan if applicable: OffBrief Risk Assessment completed by a clinician: OffRecent Discharge Summaries if applicable: OffMedication regimen or Community Treatment Order CTO: OffPhysical Health Assessment completed by a Doctor General Practitioner: OffForensic history including any current legal issues eg orders upcoming court dates: OffInterpreter required: OffSingle: OffDe facto: OffDivorced: OffMarried: OffSeparated: OffWidowed: OffChildren: OffNA_2: OffAre you under the care of a Community Mental Health Service: undefined_7: OffMEDICATION: Do you take regular prescribed medication: OffYes_60: OffNo_60: OffAre you on a Community Treatment Order CTO: OffAny hospital admissions in the last 12 months: OffDRUG AND ALCOHOL USE: Do you have a history or are you currently using drugs or alcohol: OffAre you currently smoking tobaacco: undefined_8: OffAre there any associated risk behaviours or problems eg Hepatisis injecting overdose: undefined_9: OffAre you currently accessing support around your smoking drug or alcohol use: undefined_10: OffLEGAL OFFENCES: Do you have any past or current legal issues eg Community orders pending court dates prison history: OffIf yes please provide details 1: If yes please provide details 2: If yes please provide details 3: If yes please provide details 4: Are you applying for Parole: OffHave you been assigned a Community Corrections Officer: OffSUPPORT NEEDS: Are there any particular tasks you find challenging 1: Are there any particular tasks you find challenging 2: Toileting: OffShowering: OffDressing undressing: OffClothes washing: OffCleaning: OffCooking: OffEating: OffOther_7: Offundefined_11: Gardening: OffTransport: OffShopping: OffBudgeting: OffStaying safe: OffCommunicating reading writing: OffComputer IT skills: OffOther_8: Offundefined_12: Medication: OffAdvocacy: OffAccessing services: OffAttending appointments: OffEngaging with social groups: OffFamily relationships: OffGetting in out of bed: OffOther_9: Offundefined_13: Do you get support from other services: OffAdditional comments 1: Additional comments 2: Additional comments 3: Additional comments 4: Additional comments 5: I acknowledge the information provided is correct and true: OffI agree that St Barts may contact my health community service providers to gather: OffI consent to my referral being submitted for consideration of the selected St Barts: OffDate: undefined_14: undefined_15: Applicant name 1: Applicant name 2: Date_2: undefined_16: undefined_17: Guardian name 1: Guardian name 2: applicant first name: applicant surname: applicant preferred name: app dob day: app dob month: app dob year: applicant current address: app suburb: app postcode: app email: app phone: gender: OffLGBTI: Offaboriginal/ TSI: Offdiverse: Offmain language: Offother spoken language: country of birth: referrers name: dor day: dor month: dor year: referrers organisation: referrers position: referrers email: referrers phone: visa status: who else living w you: other person name 1: other person age 1: other person name 2: other person age 2: other person relationship 2: other person name 3: other person age 3: other person relationship 1: other person gender 1: other person gender 2: other person gender 3: Do they require any support: Offhealth more info: support more info: attending school more info: Are they attending school: OffDo you have primary custody: OffIs the Department for Child Protection and Family Support DCPFS involved: OffMore information including branch and name of Case Manager: more CPFS info 2: Do they have any health issues: Offprimary custody issues: OffAge Pension: OffDisability Support Pension: OffNewstart Allowance: OffYouth Allowance: OffPaid Work: Offother income: Offother income source details: current outgoings: Do you hold a Department of Veterans Affairs DVA Health Card: Offcrn: crn expiry: medicare number: medicare expiry: Have you stayed at St Barts before: Offlast st barts stay: housing history 1: housing history 2: Privately owned: OffRental: OffWith carer family: OffWith friends: OffSupported: OffHostel: OffHospital: OffHomeless: OffOther_2: Offother living sit: Are you on the Housing waitlist: OffDo you have a Clinical Case Manager: OffDo you have a Doctor General Practitioner GP: OffDo you have a Psychiatrist: OffDo you have a Guardian: OffDo you have a Public Trustee: Offnok: nok relationship: nok email: nok phone: ccm email: ccm name: ccm phone: GP email: GP name: GP phone: psych email: psych name: psych phone: guardian email: guardian name: guardian phone: public trustee email: public trustree name: public trustee phone: carer: Offcarer email: carer name: carer phone: Child: OffAged person: OffOther_3: Offother carer type: DCPFS email: DCPFS name: DCPFS phone: DCPFS branch: DCPFS case worker: Offcco location: cco email: cco name: cco phone: other support person: other support email: other support name: other support phone: CCO: Offspecify disability: disability na: OffDo you have a current NDIS Plan: OffYes_25: OffNo_26: Offdisability support details 1: disability support details 2: diabetes: Offheart complaint: Offliver disease: Offepilepsy: OffHIV / Aids: Offhep a: Offhep b: Offhep c: Offhep d: Offlow blood pressure: Offhigh blood pressure: Offspeech impairment: Offvisual impairment: Offhearing impairment: Offmobility impairment: Offfalls risk: Offrespiratory disease: Offbruise/bleed easy: Offskin conditions: Offstomach conditions: Offasthma: Offanaphylatic: Offmedication allergy: Offpregnant: Offacquired brain injury: Offthyroid problem: Offeating disorder: Offmedical allergy: Offsubstance use: Offother condtion 2: Offother condition 1: Offother consition 1 box: other condition box 2: If you ticked yes to any of the above please provide details 1: If you ticked yes to any of the above please provide details 2: If you ticked yes to any of the above please provide details 3: If you ticked yes to any of the above please provide details 4: other person relationship 3: Submit form: