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Harmony House Referral Form
Harmony House Referral Form
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Referral Forms
I am filling out this form as a*
*
- required
Referrer
Self-Referrer
Personal Details
Full Name
*
- required
DOB
*
- required
Gender Identity
[Gender Identity]
Female
Male
Non-binary
Transgender
Intersex
I identify as another gender
I prefer not to say
Email
Phone
*
- required
Current Address
Suburb
Postcode
*
- required
Preferred Method of Contact
Phone
Email
Identify as:
Aboriginal or Torres Strait Islander
Culturally and Linguistically Diverse
LGBTIQA+
Other
Hidden
Preferred Language
Interpreter Services Required
Yes
No
Details of NDIS Plan
NDIS Number
*
- required
Plan Start Date
*
- required
Plan End Date
*
- required
Do you have a Support Coordinator?
*
- required
Yes
No
Funding Management Type:
*
- required
NDIA Managed
Plan Managed
Self Managed
Plan Manager Details
Emergency Contact
Name
Address
Phone
Email
Relationship to Individual
Referrer's Details (if applies)
Name
Position or relationship to Individual
Organisation Name
Email
Phone
Conditions
Primary Diagnosis
*
- required
Secondary Diagnosis
Allergies
No allergies currently identified
Service Delivery Details
Current Access to Services
GP
Psychiatrist
Psychologist
Social Worker
Details of Any Risks
Suicide
Self-Harm
Alcohol and/or other drugs
No Current Identified
Other Risks (please specify)
Living Arrangements
Living Alone
Homeless
Supported Accommodation
In patient (Hospital)
Other Living Arrangements (please specify)
Other Services Currently Being Received
Reason for referral
Individual support
Yes
No
Group support
Yes
No
Hours of support (please specify)
Days of support (please specify)
Would you like to add any further information that you feel we should know?
I hereby 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.
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