HEALTH PROFESSIONAL REFERRAL INFORMATION SHEET

Complete the Health Professional Referral Information Sheet and return it to us via email, in person or by fax.

Accommodation Services Mark’s Place (Carer’s respite) / Warren I’Anson House (Participants respite) T: 02 6296 2291 F: 02 6296 3136 E: [email protected] or [email protected]

Participants/Carers of the program need to be: A person with a mental illness over the age of 18, and/or a carer of a person with a mental illness, Self-managing in general household chores,

Self-managing in all treatment and medication regimes or have support workers who provide

this service, Willing to participate in the program,

Willing to abide by the house rules,

Willing to sign a consent form for the release of information,

Able to live in a house unsupervised

Non-violent, and not suicidal, acutely psychiatrically disturbed, at risk of self-harm or present

a threat to others Have their own accommodation to return to when the service ends

The program is not a crisis accommodation service.

We are not a clinical service. It is expected that residents will maintain regular contact with their mental health service clinical manager or other clinical supports.

HEALTH PROFESSIONAL REFERRAL FORM

Carer Respite Self-Referral Form Version 4.0 Date 19/07/20156 Please answer all questions. Full and frank disclosure is expected when completing the form. This will help us to provide the best possible care during your stay.

1. Today’s Date:

Please provide the following information about the person making the referral (you). Name Organisation/Job Title Phone Email

2. How many people are planning to stay

Who Number of People Carers Participant Children under 18 yrs (maximum 3)

3. Do any of the other people planning to stay have a mental illness or other disability Yes No

If Yes Please provide Details

4. Please indicate if the participant is currently receiving any of these ACT Mental Health Services. City Mental Health MITT North

Belconnen Mental Health MITT South

Woden Mental Health Older Persons Mental Health

Tuggeranong Mental Health Other (Please Specify Below)

5. Please provide the following information about the carer of person being referred.

Male Female Other ______

Carer Details Name Date of Birth Address Postcode Home Phone Mobile Relation to Email Address Consumer Does the Aboriginal or Torres Strait Islander person identify with either of

Carer Respite Self-Referral Form Version 4.0 Date 19/07/20156 these cultural Diverse Cultural and Linguistic Background backgrounds? Preferred Do you require Country of Birth Language an interpreter?

6. Please provide the following information about the person being referred: Male Female Other ______

Participant Details Name Date of Birth NDIS number Address Postcode Aboriginal or Torres Strait Islander Does the person identify with either of these cultural backgrounds? Diverse Cultural and Linguistic Background

Phone Mobile

7. What is the reason for referral?

Clinical Information 8. Name and contact details of Health Professionals involved in the consumer’s care. Clinical Manager: Phone: Other: Phone:

9. Does the participant experience any marked disturbances of mood? (e.g. depression or mania) No Yes (please give specific details describing the nature and frequency and current state)

10. Does the participant experience any unusual perceptual experiences? (e.g. hallucinations) No Yes (give specific details including frequency, nature, current state and the consumer’s

reaction to these experiences.)

11. Does the participant experience any unusual thought content? (e.g. delusions) No Yes (please give specific details about the frequency and content of these unusual thoughts

and current state)

Carer Respite Self-Referral Form Version 4.0 Date 19/07/20156 12. List all the participants’ current medications. Medication Dose Frequency

13. Does the participant have any other medical conditions or allergies? (eg to food or medication) No Yes - please provide specific details

14. Has the participant been admitted to hospital in the past year? No

Yes - please provide specific details of admissions this year

Admission date Discharge Date Location (e.g. Reason for admission PSU)

15. Please provide information about any drug and alcohol use (current and recent history). Substance Quantity and Route How long used Last used frequency

SERVICE USER CONSENT I/we understand the information that is recorded on this form will be stored and shared for the purpose of providing services to me and my/our family. I/we understand that non-identifying information may be provided to ACT Government or The Department of Social Services (DSS), for collating statistics on service users.

Name of Person making the Signed: Date: referral (You): Name (Person being Signed: Date: referred):

Verbal consent to share information (given over the telephone)? No Yes

Carer Respite Self-Referral Form Version 4.0 Date 19/07/20156 Office Use Only

Referral Received Date Initial Contact Date Entry Interview Booked Referal Declined

Carer Respite Self-Referral Form Version 4.0 Date 19/07/20156