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Pioneer Clubhouse Referral Form
Pioneer Clubhouse Referral Form
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Referral Forms
Eligibility
Primary Diagnosis of Mental Health:
*
- required
Yes
18 or over:
*
- required
Yes
Participant does not pose significant risk toward staff and/or others:
*
- required
Yes
Centre Attendance:
*
- required
Will attend on my own
Will attend with support
Personal Details
Given Names
Surname
Preferred Name
Street Address
Suburb
Postcode
Email
Mobile
Home Phone
Date of Birth
Gender Identity
[Gender Identity]
Female
Male
Non-binary
Transgender
Intersex
I identify as another gender
I prefer not to say
Health Information
Primary Diagnosis
Secondary Diagnosis
Referral Information
Referrer's Name
Mobile
*
- required
Email
*
- required
How did you hear about Pioneer Clubhouse?
Community Mental Health Service
Hospital
Clinician (psychiatrist, psychologist)
Other, please specify
Details of Member
Identify as:
Aboriginal or Torres Strait Islander
Culturally and Linguistically Diverse
LGBTQIA+
Country of birth
Main language spoken
Living arrangements:
Lives alone
Lives with family
Lives with others
Lives in Remote Area
Homeless
Labour force status:
Employed
Unemployed
Not in Labour Force
Main income source:
Paid employment
Disability Support Pension
Jobseeker
Other sources of income?
Accessibility requirements:
Yes
No
Please provide details
Have an NDIS plan:
Yes
No
Are you willing to share a copy of your NDIS goals with us?
Yes
No
Emergency Contact
Given Names
Surname
Relationship to participant
Mobile
*
- required
Home Phone
*
- required
Email
*
- required
May we contact this person if we have concerns for your wellbeing?
Yes
No
Mandatory field(s) marked with *
X