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Bilingual Hospital 2 Home Referral Form

Bilingual Hospital 2 Home Referral Form

Eligibility Criteria (Section 1 of 6)
Please tick in the Boxes:
Personal Details (Section 2 of 6)
Identify as:
Is an interpreter required?
Family and Domestic Violence history?* - required
Does the person have an existing Mental Health Care Plan?* - required
Referrer's Details (Section 3 of 6)
Reasons for Referral (Section 4 of 6)
Hospital Admissions
Level of risk (please select the most appropriate):
Suicide
Self-Harm
Aggression
Vulnerability
Please advise on any substances used (please select the most appropriate):
Alcohol
Illicit drugs
Would you like assistance in abstaining from use?
Are you currently receiving support to assist in abstaining?
Existing support network:
Linkage to supports:
Please tick all that apply
Secondary Contact Details (Section 5 of 6)
Hospital Details (Section 6 of 6)
*If no hospital details is available, please press 'Submit'.
Legal Status on Admission
Discharge Plan attached to this referral?

*By submitting this application, I (being referred) give consent for One Door Mental Health to communicate and collect information from the referrer. I give consent for One Door Mental Health to keep a record of my referral which will remain strictly confidential and only used for its intended purpose.


Mandatory field(s) marked with *