Referral Form - SEW - Relationships Australia South Australia

Service Type*

Individual

Group

Consent to Refer*

I have discussed the proposed referral with the client/resident, and I am satisfied that they understand the proposed uses and disclosures of the information contained in the Referral Form and agree to this information being given to SEW. I understand that I can request a copy of this document once completed and that SEW will store the information provided electronically

(referrals cannot be accepted without the consent of the person being referred):

Referrer Details

Full Name*

Organisation:*

Phone*

Email*

Address*

Relationship to client/resident*

Aware of referral:

Resident:*

Yes

GP:*

Yes

Next of Kin:*

Yes

RACF:*

Yes

Facility contact person (optional)

Support Person/Next of Kin Details

Untitled

As per referrer details

Full Name:*

Phone:*

Relationship to client/ resident:*

Phone (Mobile):*

Additional details:

Referral/Assessment details:

(Including engagement with supports and treatment, outcomes, duration of symptoms, any other relevant details)

Main reason for referral:*

Please include any symptoms, how well they are coping, mental and physical health concerns (including medications), and other contributing factors

Mental health diagnosis & relevant history:*

Please include any symptoms, how well they are coping, mental and physical health concerns (including medications), and other contributing factors

Disclaimer – Please note: If a resident is at acute risk contact 000 or Mental Health Triage on 131465.

Suicidal ideation (i.e. thoughts about suicide):*

Yes

Suicidal intent (i.e. intends to act on their thoughts):*

Yes

A suicide plan (i.e. has planned how they would suicide):*

Yes

Is the resident a risk to others:*

Yes

Significant life events:*

Family supports & history:*

Social Networks & Hobbies:*

Other details

(where not already provided above)

Social Networks & Hobbies:*

Please send completed document to MHRACF@rasa.org.au

Referral Form – SEW