Disability and Aged Care Support Services Perth Western Australia

Outreach Referral Form

NDIS

NDIS is a service that endeavours to provide individualised support for people with an ongoing mental health diagnosis. NDIS takes a person-centred strength based approach, working with participants, their families and carers to develop an individualised plan. NDIS aims to connect participants with their community, and mainstream supports help participants pursue their goals and aspirations to participate in everyday life. Please visit our website at www.halefoundation.com.au, to find out which scheme you can apply for. Hale Foundation is able to assist in applying to NDIS, support co- ordination of an existing plan, and/or service delivery.
More information on each of these services is available on our website www.halefoundation.com.au. If you require assistance in selecting the right service, please contact our Intake Officer at info@halefoundation.com.au or 0401 030 030.

    Referrer Details

    Name *

    Agency / Position

    Postal Address

    Postcode

    Phone *

    Email

    How did you hear about us? *

    Other


    Applicant to Complete

    First Name *

    Family Name *

    Preferred Name

    Date of Birth *

    Address *

    Postcode *

    Email

    Phone

    Mobile *

    Gender

    If Different Identity (please describe)

    Sexuality

    Other

    Intersex status

    Pronouns

    Other

    Relationship Status

    Relationship other

    Aboriginal

    Torres Strait origin

    Ethnicity

    Country of Birth

    Culturally and Linguistically Diverse

    Main Language spoken

    Other

    Interpreter required

    Children

    Visa status

    Occupation

    Source of income

    Other (please specify)

    Living Situation

    Other

    Hold a DVA Card?

    If yes, what type?

    Contacts

    Nominated support person (Next of kin / Alternative contact)


    Name

    Phone

    Mobile

    Email

    Relationship

    Do you have a Case Manager?

    Name

    Organisation

    Phone

    Mobile

    Email

    Do you have a Guardian Appointed?

    Name

    Phone

    Mobile

    Email

    Do you have a Public Trustee?

    Name

    Phone

    Mobile

    Email

    Do you have a GP?

    Name

    Phone

    Mobile

    Email

    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 *

    Upload supporting documents

    Attachments