Referral Form

Eligibility Criteria

Consumers must meet all 7 eligibility requirements to be eligible for PIR.

Eligibility Criteria

Live in the South West Sydney Region
Are Australian Citizen’s or Permanent Resident’s (Or NZ Citizen’s with a Special Category protected Visa) Experience a long term and severe mental health condition that is likely to be permanent
Experience significantly reduced functional capacity due to a mental health condition
Despite past treatments their mental health condition continues to impact on their lives
Interested in applying for the NDIS – National Disability Insurance Scheme
Are under 65 years of age

Has the consumer given permission to have the referral made on their behalf?

Yes
No

Is the Consumer aware of the NDIS – National Disability Scheme?

Yes
No

Details of person being referred to Partners in Recovery

Full Name*

Date of Birth

Gender

Current Address

Mobile Phone

Home Phone

Can we leave voicemail on the number provided?

Yes
No

Email Address

Country of Birth

Interpreter required?

Yes
No

If yes, which language

Does the Consumer identify as

Aboriginal
Torres Strait Islander

Referrer's Details

Referrer's Name

Organisation Name

Location

Position or relationship to Consumer

Telephone

Email

National Disability Insurance Scheme

Select the box that best applies to the consumer.

The consumer has heard and understands what the NDIS can do to support them
The consumer has requested an NDIS form but has not yet completed the submission
The consumer has already submitted an NDIS application and is waiting for an outcome
The consumer may be interested in submitting an NDIS application in the future

Mental health Information

Please list the consumer’s mental health issues:

Has the Consumer's mental illness been formally diagnosed?

Yes
No

Who was the diagnosis performed by?

How old was the Consumer when their mental health began impacting their lives?

Is the Consumer currently seeing a medical professional for mental health; please tick any appropriate boxes:

Psychologist
Psychiatrist
GP
Councillor

Has the consumer been hospitalised for your mental health needs within the last three years?

Yes
No

Please give details of hospitalisations including where, when and for how long:

Current Supports

Is the consumer currently receiving support from one or more of the following?

Please select the boxes that best apply to the consumer:

Psychologist
Psychiatrist
GP
Counsellor
Community Mental Health
Other Support Program

Is the consumer currently taking medication for their mental Health?

Yes
No

Please explain what services or treatment options that the consumer has tried in the past, to assist them with their mental health?

Financial Situation

The consumer currently receives income from*

Please select the boxes that best apply to the consumer

An income from work
Newstart Payment
Carers Allowance
DSP Payment
Parenting Payment
Sickness Benefit
Applying for a DSP Payment

Functional Capacity

Considering your ability to function daily please tick the boxes where the consumer requires further assistance.

Supports Needed

Other

Other Conditions

Please list any other conditions that the consumer experiences that impact on their ability to function on a daily basis, this may include physical and intellectual problems:

Once your referral has been accepted by PIR it will be forwarded to the PIR Team closest to your location. At this time a Support Facilitation Officer will contact you for further discussion

If you have any further questions please contact our Intake Office on the below number.

Partners in Recovery Referral Form

Eligibility Criteria

Details of person being referred to Partners in Recovery

Referrer's Details

National Disability Insurance Scheme

Mental health Information

Current Supports

Financial Situation

Functional Capacity

Supports Needed

Other Conditions

For More information