Over 10 years we help companies reach their financial and branding goals. Engitech is a values-driven technology agency dedicated.

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411 University St, Seattle, USA

engitech@oceanthemes.net

+1 -800-456-478-23

Outreach Referral Form

    Referrer Details

    Name *

    Agency / Position

    Postal Address

    Postcode

    Phone *

    Email

    How did you hear about us? *

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    Applicant to Complete

    First Name *

    Family Name *

    Preferred Name

    Date of Birth *

    Address *

    Postcode *

    Email

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    Mobile *

    Gender

    If Different Identity (please describe)

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    Interpreter required

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    Living Situation

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    Hold a DVA Card?

    If yes, what type?

    Contacts

    Nominated support person (Next of kin / Alternative contact)

    Name

    Phone

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    Relationship

    Do you have a Case Manager?

    Name

    Organisation

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    Do you have a Guardian Appointed?

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    Do you have a Public Trustee?

    Name

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    Do you have a GP?

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    Which of the above is your preferred contact?

    Preferred method of contact?

    Support and Areas of Need

    Service you are seeking

    Existing NDIS Plan (please attach)

    NDIS Plan Number (Please attach)

    Current diagnosis / disability *

    If yes, please provide details:

    Do you currently receive support from a service?

    If yes, where from?

    Previously applied for Hale Foundation?

    Are there recovery steps you are working towards?

    Can you share them?

    Are there some specific areas you would like support to access i.e. education, employment, recovery planning, navigating life problems, things around the house?

    What has helped you in your recovery thus far?

    What are you passionate about?

    Health and Wellbeing

    4.1 Any mental health issues you currently receive treatment or support for?

    If yes, when did you first receive treatment/support for this?

    4.2 Any physical health concerns you currently receive treatment or support for?

    If yes, how long have you received treatment for this?

    4.3 Describe how your answers from Questions 4.1 and 4.2 impact your life.

    Do you have any legal issues we need to know about? (E.g. outstanding charges, convictions or a community treatment order)

    If yes, please provide details:

    Do you have any Alcohol or Drug issues?

    If yes, please provide details:

    Are you linked in with any Alcohol or Drug services?

    If yes, please provide details:

    Consent

    I acknowledge the information provided is true and correct.
    I agree that Hale Foundation may contact my health service providers to gather additional information to assist with my referral if needed.

    Name of consenting applicant *

    Date *

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