<p> HEALTH PROFESSIONAL REFERRAL INFORMATION SHEET</p><p>Complete the Health Professional Referral Information Sheet and return it to us via email, in person or by fax.</p><p>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] </p><p>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,</p><p>Self-managing in all treatment and medication regimes or have support workers who provide </p><p> this service, Willing to participate in the program, </p><p>Willing to abide by the house rules,</p><p>Willing to sign a consent form for the release of information,</p><p>Able to live in a house unsupervised </p><p>Non-violent, and not suicidal, acutely psychiatrically disturbed, at risk of self-harm or present </p><p> a threat to others Have their own accommodation to return to when the service ends</p><p>The program is not a crisis accommodation service.</p><p>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. </p><p>HEALTH PROFESSIONAL REFERRAL FORM</p><p>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. </p><p>1. Today’s Date: </p><p>Please provide the following information about the person making the referral (you). Name Organisation/Job Title Phone Email </p><p>2. How many people are planning to stay</p><p>Who Number of People Carers Participant Children under 18 yrs (maximum 3)</p><p>3. Do any of the other people planning to stay have a mental illness or other disability Yes No</p><p>If Yes Please provide Details</p><p>4. Please indicate if the participant is currently receiving any of these ACT Mental Health Services. City Mental Health MITT North</p><p>Belconnen Mental Health MITT South</p><p>Woden Mental Health Older Persons Mental Health</p><p>Tuggeranong Mental Health Other (Please Specify Below)</p><p>5. Please provide the following information about the carer of person being referred.</p><p>Male Female Other ______</p><p>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 </p><p>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?</p><p>6. Please provide the following information about the person being referred: Male Female Other ______</p><p>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</p><p>Phone Mobile</p><p>7. What is the reason for referral?</p><p>Clinical Information 8. Name and contact details of Health Professionals involved in the consumer’s care. Clinical Manager: Phone: Other: Phone: </p><p>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)</p><p>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 </p><p> reaction to these experiences.)</p><p>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 </p><p> and current state)</p><p>Carer Respite Self-Referral Form Version 4.0 Date 19/07/20156 12. List all the participants’ current medications. Medication Dose Frequency</p><p>13. Does the participant have any other medical conditions or allergies? (eg to food or medication) No Yes - please provide specific details</p><p>14. Has the participant been admitted to hospital in the past year? No</p><p>Yes - please provide specific details of admissions this year</p><p>Admission date Discharge Date Location (e.g. Reason for admission PSU)</p><p>15. Please provide information about any drug and alcohol use (current and recent history). Substance Quantity and Route How long used Last used frequency</p><p>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. </p><p>Name of Person making the Signed: Date: referral (You): Name (Person being Signed: Date: referred): </p><p>Verbal consent to share information (given over the telephone)? No Yes </p><p>Carer Respite Self-Referral Form Version 4.0 Date 19/07/20156 Office Use Only</p><p>Referral Received Date Initial Contact Date Entry Interview Booked Referal Declined</p><p>Carer Respite Self-Referral Form Version 4.0 Date 19/07/20156</p>