National Counselling Program (Victoria) An Australian Government Initiative REFERRAL FORM Please complete all sections each time a request is made for counselling REFERRAL DETAILS Date of referral: Referrer’s name: Position: Organisation: Address: Suburb: Postcode: Contact number: Referrer’s email: SOURCE OF REFERRAL Self Family, friend, significant other Carer Advisory Service CRCC Aged or disability assessment service HACC Assessment authority Community Nursing service Acute care hospital Psychiatric / mental health facility (please specify below) Summary of carer’s current circumstances CARER DETAILS First Name: Last Name: Residential address: Suburb: Postcode: Postal Address (if different to residential): Suburb: Postcode: CONTACT NUMBERS Is it OK to leave a message? Home: Yes No Work: Yes No Mobile: Yes No Preferred day/time to call: Email: Date of birth: Gender: Male Female Other Country of birth: Cultural identity: language (other than English): Interpreter required?: Yes No Aboriginal or Torres Strait Islander: Neither Aboriginal no Torres Strait Islander: COUNSELLING TYPE REQUESTED Individual Group Couple/family For couple/family counselling, complete name of other members at bottom of page. COUPLE/FAMILY COUNSELLING DETAILS (other members attending) All members wishing to attend counselling must provide consent for this referral. Name: Relationship to care recipient: Date of birth: Name: Relationship to care recipient: Date of birth: CARER DETAILS (continued) CARER RECEIVING GOVERNMENT INCOME SUPPORT PAYMENT (Tick any that apply)
Age pension Veterans’ Affairs pension Disability support pension Carer Payment Carer Allowance Unemployment related allowance Other government pension / allowance No government income support payment EMPLOYMENT Full time employed Part time employed Not in paid employment Unemployed allowance Retired LENGTH OF TIME AS Less than 2 years 2–4 years 5–9 years 10–24 years More than 25 years CARER ROLE Primary carer Other carer CARE RECIPIENT DETAILS Number of care recipients If there are more than two care recipients, please include their information on a separate piece of paper. Care Recipient 1 Care recipient’s relationship to carer Care recipient’s age Is care recipient living with carer? Care recipient’s postcode Care Recipient Condition (Tick all that apply) Frail aged (65+ or 50+ for indigenous) Dementia Person under 65 with a disability Chronic illness In need of palliative care Mental illness Specify condition/diagnosis CARE RECIPIENT DETAILS (continued) Care Recipient 2 Care recipient’s relationship to carer: Care recipient’s age: Is care recipient living with carer?: Care recipient’s postcode: Care Recipient Condition (Tick all that apply) Frail aged (65+ or 50+ for indigenous) Dementia Person under 65 with a disability Chronic illness In need of palliative care Mental illness Specify condition/diagnosis SEEKING COUNSELLING DUE TO Recent commencement of caring role of care recipient Negative change in condition of care recipient Negative change in health of carer Care recipient to residential care Financial strain Change in household composition Ongoing stress of carer role Other Signature of person completing form Carer consent: I consent to the information disclosed on this form being provided to Carers Victoria for the purposes of referral and assessment for counselling services and inclusion in de-identified data reporting. I understand that Carers Victoria may contact me in relation to this referral and conduct further assessment. Further information on Carers Victoria’s Privacy Policy is available at Signature of Or verbal consent obtained by: Name Date of verbal consent Mail to: NCCP Carers Victoria PO Box 2204 FOOTSCRAY VIC 3011 Fax to: (03) 9396 9595 Email: For referral enquiries call Carer Advisory Line on 1800 242 636