Expressions of Interest & Referral Form

The Rivers Program aims to deliver a wide range of enriching peer led group activities and experiences to people all over the Perth metropolitan area who are aged between 16-65 and identify that their mental health impacts on their personal wellbeing.

If you are interested in participating, please complete the form below or download the PDF here.

Client Details

Do you have an active NDIS plan? *

YesNo

Please note: having an NDIS will not prevent you from attending.

First Name *

Last Name *

Preferred Name

DOB

Phone Number *

Email Address *

Address

Gender

Pronouns

Country of birth

Preferred Language

Do you identify yourself as being:

AboriginalTorres Strait Islander NeitherPrefer not to say

Do you identify as part of the LGBTIQA+ community:

YesNo Prefer not to say

If you identify with a particular ethnicity, please advise below.

Emergency Contact Details

Name *

Relationship *

Phone Number *

Email Address *

Address

Do you have a carer/guardian? *

YesNo

If yes, please provide details:

Referrer Information

Referrer Details

Clinical Mental Health Social Worker General Practitioner Self-referral

Name

Phone Number

Email Address

Mental Health

Does your mental health impact your wellbeing?

Does this impact on daily life skills, social interactions, and independence?

If you answered yes, please provide further details below.

Co-existing Health

Alcohol or Drug Use

YesNo

Physical Disability

YesNo

Acquired Brain Injury

YesNo

Intellectual Disability

YesNo

If you answered yes, please provide further details below.

Please provide details of any other health concerns

Client Interests and Requested Services

Educational WorkshopsRecreational/Sporting ActivitiesSocial ConnectionArts/Crafts

If you have seen a specific group program on our Rivers activities calendar you are interested in attending, please note here:

Consent to Referral

The individual being referred has agreed that their information be shared with Rise and associated agencies connected to the delivery of the group activities. *

Yes

The individual being referred agrees and acknowledges that the above consent will be valid indefinitely unless stated otherwise or withdrawn in writing by the client or legal guardian. *

Yes

For security please complete the check below *