Individual Support Referral Form Mental Health

The Individual Support Programs (Psychosocial & Peer Support) provide outreach supports to individuals with enduring mental health challenges, living in the Swan and North Metropolitan Health service area. Supports are provided in line with the Mental Health Commission Outcome Statements, a copy of which can be found here.

Eligibility Criteria:

Individuals can be in a range of accommodation settings, including community housing, private rentals, own home, and alternate living arrangements.
Must be between 18 – 65 years of age.
Have severe and persistent mental health: formally diagnosed or self-identified.
They must have guaranteed on-going clinical support (GP, Psychologist, Psychiatrist, Community Mental Health) and not currently receiving NDIS funding or supports.
Reside within our catchment area (25-minute drive from Rise head office, located in Middle Swan).
Willingness and ability to engage in psychosocial supports to live successfully in the community.

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

Individual being Referred

First Name *

Last Name *

Preferred Name

Date Of Birth

Phone Number *

Email Address *

Address

Does the individual identify as being:

AboriginalTorres Strait Islander NeitherPrefer not to say

Culturally and linguistically diverse background:

YesNo

Preferred Language

Interpreter required:

YesNo

Current living arrangements (e.g., lives with family).

Next of Kin

Any dependents:

YesNo

If yes, please provide details:

Does the individual have a carer/guardian:

YesNo

If yes, please provide details:

Guardianship or Administration order in place:

YesNo

If yes, please provide details.

Referrer Information

Name

Practice/Clinic:

Address

Postcode

Phone Number

Email Address

Other supports

GP Name

Phone

Psychiatrist Name

Phone

Psychologist Name

Phone

Is the individual currently receiving any other supports or services?

Worker Related Preferences

Does the individual being referred have any Worker Related Preferences? Note: A Peer Worker is someone who has lived experience of mental health recovery

MH Support Worker MH Peer Support Worker No Preference

If engaged with a Peer Worker, would the individual like to participate in activities such as Peer Workshops?

YesNo

Mental Health

Serious and persistent Mental Illness:

YesNo

Primary diagnosis

Diagnosis Date

Secondary Diagnosis

Diagnosis Date

Mental health and wellbeing history, e.g., hospital admissions, early warning signs, and case management strategies.

What goals has the individual identified that they would like support with i.e., employment, recovery planning, accessing community supports?

Are there any functional impacts on daily life skills, social interactions, and independence?

Health Information – Co-existing Health Issues

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

Other relevant information

Disability Support Pension?

YesNo

NDIS eligibility tested?

YesNo

If yes, what was the outcome?

Legal/Forensic Issues?

YesNo

If yes, please provide details, including any PSOLIS alerts.

Risk Assessment

At risk of harm to self or others?

YesNo

Previous incidents of aggression and/or violence?

YesNo

Current or historic use of unhealthy coping strategies? i.e. Self-harm, risk taking behaviours.

YesNo

Previous use of weapons?

YesNo

If you answered yes to any of the above, please provide details.

Consent to Referral

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 *