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Carer Services Referral Form

Family and Carer Mental Health Program Referral Form - Southern NSW LGA

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Referral Forms

Carer Information

Given Names* - required

DOB

Gender Identity

Email* - required

Phone* - required

Address

Postcode* - required

State

Identify as

Aboriginal or Torres Strait Islander

Culturally and Linguistically Diverse

LGBTQIA+

Young

Aged

Lives in Rural Area

Lives in Remote Area

Full-Time or Part-Time Worker

Interpreter Required

Yes

No

Language

Details of the Referrer/Agent (if any)

Name

Organisation - if applicable

Email

Phone

Fax

Address

Postcode

State

Relationship to client

Permission to contact family/carer

Yes

No

Does the carer have children

Yes

No

Care Recipient Details (Optional)

Name

DOB

Linked to mental health services

Yes

No

If yes, name of the MH service

Diagnosis if known

Types of Support Required

Checkbox List

Information

Education

Emotional Support

Advocacy

Referral Checklist

Family/Carer is caring for an individual with a primary diagnosis of mental illness?* - required

Yes

No

Relationship to the person you are caring for* - required

Referral has been discussed with family/carer.* - required

Yes

No

Does the family/carer live within the Southern NSW Region* - required

Yes

No

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Mandatory field(s) marked with *

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One Door Mental Health is a leading specialist mental health provider. For more than 35 years, One Door has designed and delivered expert mental health programs that are now accessible through the NDIS.

Through One Door, people living with mental illness and their families can find an inclusive community, innovative services and advocacy support. Creating a world in which people with a mental illness are valued and treated as equals is at the heart of everything we do.

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1800 843 539

Support Hub

27 Fennell Street
Parramatta NSW 2150

Postal Address

PO Box 2258
North Parramatta NSW 1750 Australia

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NDIS Provider Number: 405 0000 179 | ABN: 58 903 786 913

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