Referral Form

Eligibility Criteria

Please tick the relevant boxes

Eligibility Criteria

Live in the South West Sydney Local Government Area.
Have a mental illness that is severe in degree and persistent in duration. (No formal diagnosis is required).
Require substantial supports and assistance to engage with various services to meet their needs. E.g. of supports would be housing, finance, employment, education, social engagement.
Aged between 25 and 64 yrs old.
Have no existing coordination arrangement in place to assist the person accessing the necessary services, or when they are in place, those arrangements have failed, have contributed to the problems experienced by the person, and are likely to be addressed by acceptance into PIR.
Applicant must have given consent to have the referral made on their behalf.

Referrer's Details

Title*

First Name*

Surname*

Organisation

Job Title

Contact Number

Email

Client Details

Name

Date of Birth

Address

Contact Numbers (Home & Mobile)

Email

Country of Birth

Nationality

Ethnicity (Cultural background)

Sub Ethnicity

Are you?

Aboriginal
Torres Strait Islander

Do you require an interpreter? What language?

Emergency Contact Person / Next of Kin

Name

Phone

Relationship

NDIS

Do you have a National Disability Insurance Scheme funded package in place?

Yes
No

Comments

Mental Health History

Mental health issues

Has your mental health illness been formally diagnosed by a medical professional

Yes
No

What age were you when you were first diagnosed?

Are you currently seeing a medical professional for your mental health (please give details)

Have you been hospitalised with your mental health in the last:

10 Years

Yes
No

How many times?

12 months

Yes
No

How many times?

Details of recent hospitalisations

Mental Health

Please explain in detail how your mental health affects you life.

PIR can assist with a variety of supports, an example of those supports include but are not limited to assistance with finding employment, housing, drug and alcohol issues, social supports, legal issues, and relationships.

In this section please explain what it is you would like PIR to help you with:

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

Referrer's Details

Client Details

Emergency Contact Person / Next of Kin

NDIS

Mental Health History

Mental Health

For More information