REFERRAL FOR PROSPECTIVE CLIENTS

Transcription

1 REFERRAL FOR PROSPECTIVE CLIENTS Tips for Completing this form: Eligibility for Accommodation: males aged 18 and over at risk of, or currently experiencing homelessness. (over 65 must have level of independence) This form is divided into 5 sections. Section 1 and 5 should be completed on all referrals and the relevant section on Mental Health, Health and Offending Behaviour completed, in full depending upon the issues the individual presents with. The form should be completed in the presence of the client providing as much information as possible to enable a full assessment to be completed in a timely manner. Should the information not be provided their may be delays in providing accommodation. Incomplete referrals will be returned. Any instances where the referrer does not know information this should be stated clearly. Once completed the form should be ed to HTSS.referrals@stbarts.org.au and or sent by fax to A confirmation will be provided on receipt of the referral and a response to the referral will be provided by phone within 7 days. Should you be unsure of the applicants suitability you can contact the Coordinator on or SECTION 1 PROSPECTIVE CLIENT INFORMATION SURNAME: GIVEN NAME(S) Date of Birth: Contact Phone Number: CurrentAddress: CRN: Payment Type (Newstart, Pension, Allowance) Medicare Number: Expiry Date: Has the client been a resident of St Bartholomew s previously? Yes No If yes, please state when and which location/program: Next of Kin: Relationship: Address: Contact Number (Business Hours) After Hours Does the perspective client have any form of disability/ high needs? Yes No If Yes, Please give details, e.g. Intellectual, Physical, Mental Health, Sight, Hearing, Drug & alcohol Details: 1

2 SECTION 2 MENTAL HEALTH NOTE: This Section should be completed by a treating doctor or mental health clinician with access to clients medical history. Diagnosis: Is the client currently prescribed medications Yes No List Medications Dose When to be taken/how often Are these symptoms current? Date the client first diagnosed? When did the client last relapse? What caused the relapse? Has the client ever been admitted to a psychiatric hospital / psychiatric ward? Yes No If yes, please advise where, when, Length of admission, number of admissions: Are there any PSOLIS alerts for this person? If so, what? Is the person on a Community Treatment Order? Yes No If yes please provide more information Date of Order: Length of Order: 2

3 Conditions of Order: Does the person have a history of non compliance with medication: Yes No What is the reason for non compliance i.e. homelessness, not wanting to take medications etc? _ Does the client have a history of self harm or attempted suicide: Yes No If yes please give more information(date of attempts, self harm behaviours): Is there any history of hostility and/or aggression toward other people Verbal of Physical? Please include dates of incident and nature of the incident: Yes No Does the client have an alcohol and/or drug dependency: Yes No If yes please give more information (Date of last use / alcoholic drink/ frequency of use): Has the client participated in any Rehab or Detox programs? Yes No If yes please provide more information on programs and dates: _ Does the client wish to seek any counselling support for a substance misuse issue? Yes No Is the perspective client currently seeing a Psychiatrist or Mental Health Worker on a regular basis? Yes No If yes, please provide the following details: 3

4 Name of Doctor: Address: Telephone Number Frequency of Visits Name of Key/CaseWoker: Address: Telephone Number: Frequency of Visits: Is the client able to attend to the following independently: Client Initial change their linen Yes No vacuum/sweep/mop floors Yes No budget Yes No go food shopping Yes No cook nutritious meals Yes No maintain personal hygiene Yes No Purchase their own medications Yes No Manage their own medication Yes No If no has been answered to any of the above: What support has been organised (i.e. silver chain, pharmacy managed medications): How often will this service attend: What support will they provide: Is there any other information that you believe is relevant in providing a safe environment for the client, other clients, visitors, carers, staff and the community of St Bartholomew s House? Yes No 4

5 If yes please give details, and our Coordinator will telephone to discuss this with you further. Name of practitioner completing form Position Signature Date PLEASE ENSURE THE CLIENT COMPLETES AND SIGNS THE ATTACHED CONSENT FORM IN SECTION 5. ANY ACCOMODATION OFFERED TO CLIENTS IS ON A TRIAL BASIS & SUPPORT FROM THE INVOLVED CASE WORKER WILL BE SOUGHT. 5

6 SECTION 3 PHYSICAL HEALTH NOTE: This Section should be completed by a treating doctor with access to clients medical history. What Medical conditions/diagnosis does the client currently have: Is the client currently prescribed medications Yes No List Medications Dose When to be taken/how often Due to the medical condition what is the clients functioning capacity with daily living skills? Mobility can they climb stairs, is an aid required (wheelchair, walking sticks, frame): Yes No If yes, what is used: Is the client able to attend to the following independently: Client Initial change their linen Yes No vacuum/sweep/mop floors Yes No budget Yes No go food shopping Yes No cook nutritious meals Yes No maintain personal hygiene Yes No Purchase their own medications Yes No Manage their own medication Yes No If no has been answered to any of the above: What support has been organised (i.e. silver chain): 6

7 How often will this service attend: What support will they provide: Drug & Alcohol Use Does the client have an alcohol and/or drug dependency: Yes No If yes please give more information (Date of last use / alcoholic drink/ frequency of use): Has the client participated in any Rehab or Detox programs? Yes No If yes please provide more information on programs and dates: _ Does the client wish to seek any counselling support for a substance misuse issue? Yes No Name of Practitioner completing form Position Signature Date If this is not the individuals regular doctor please provide the information below; Name of Doctor: Address: Telephone Number Frequency of Visits PLEASE ENSURE THE CLIENT COMPLETES AND SIGNS THE ATTACHED CONSENT FORM -SECTION 5. 7

8 SECTION 4 PRISON RELEASE This section must be completed by the Community Corrections Officer. Prison Release date: Prison held in: Please list all Charges / Convictions Length of Sentence Length of time served Is the prospective client on Parole? Yes No How long is the parole: What are the conditions of Parole (e.g. reporting to Corrective services daily, weekly, drug counselling, Urine testing, no unsupervised access to children, not to leave the State ) What has been put in place to assist the client to re-integrate into society. ( e.g. Rehabilitation programs) Where will the prospective client report to? 8

9 Name of Parole Officer Address Telephone Mobile Who to contact after hours Telephone Mobile Has the prospective client been incarcerated previously Yes No If yes, please provide more details- (e.g. Dates & number of incarcerations, Charges / Convictions, Length of sentence etc) Please list all courses, educational programs, groups completed during incarceration (e.g. anger management, sexual offenders, Drug & Alcohol counselling, First Aid, Year 11 & 12.etc) Does the perspective client suffer with Mental Health Issues? Yes No If yes, please state diagnosis below and have a Mental Health Profession complete Section 2 Does the client have any health issues/ take medication? Yes No 9

10 If Yes, please state the health conditions and medications below and have a doctor/ health practitioner complete Section 3. Does the client have any family supports in Perth Yes No If yes, please provide details Name Address Telephone Mobile Is the client able to attend to the following independently: Client Initial change their linen Yes No vacuum/sweep/mop floors Yes No budget Yes No go food shopping Yes No cook nutritious meals Yes No maintain personal hygiene Yes No Purchase their own medications Yes No Manage their own medication Yes No If no has been answered to any of the above: What support has been organised (i.e. silver chain): How often will this service attend: What support will they provide: Name of Practitioner/Officer completing form Position Signature Date PLEASE ENSURE THE CLIENT COMPLETES AND SIGNS THE ATTACHED CONSENT FORM. ANY ACCOMODATION OFFERED TO CLIENTS IS ON A TRIAL BASIS. 10

11 SECTION 5: CONSENT FORM I, (Client Name) GIVE MY PERMISSION TO ALLOW THE ST BARTHOLOMEW`S HOUSE STAFF TO OBTAIN ANY INFORMATION FROM THE FOLLOWING SERVICES TO ASSIST MY APPLICATION FOR SHORT TO MEDIUM TERM ACCOMODATION. SERVICE PROVIDER Initial CENTRELINK MENTAL HEALTH SERVICES DEPARTMENT OF COMMUNITY CORRECTIONS DISABILITY SERVICES COMMISION DEPARTMENT OF IMMIGRATION WESTERN AUSTRALIA POLICE SERVICE MEDICAL PRACTIONIONER HEALTH / TREATMENT CENTRE`S OTHER SERVICE`S-Please List any other agencies the client is linked with which St Bart s may need to contact for support purposes. CLIENT SIGNATURE DATE G:\102A - Standard Documents - Pdfs\Forms\HTSS\HTSS\Referral For Prospective Residents Doc 11