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Carer Services Referral Form
Family and Carer Mental Health Program Referral Form - Hunter New England LGA
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Carer Information
Given Names
*
- required
DOB
Gender Identity
[Gender Identity]
Female
Male
Non-binary
Transgender
Intersex
I identify as another gender
I prefer not to say
Email
*
- required
Phone
*
- required
Suburb
*
- required
Postcode
*
- required
State
Identify as
Aboriginal or Torres Strait Islander
Culturally and Linguistically Diverse
LGBTQIA+
Young
Aged
Lives in Rural Area
Lives in Remote Area
Full-Time or Part-Time Worker
Interpreter Required
Yes
No
Language
Details of the Referrer/Agent (if any)
Name
Organisation - if applicable
Email
Phone
Fax
Address
Postcode
State
Relationship to client
Permission to contact family/carer
Yes
No
Does the carer have children
Yes
No
Care Recipient Details (Optional)
Name
DOB
Linked to mental health services
Yes
No
If yes, name of the MH service
Diagnosis if known
Types of Support Required
Checkbox List
Information
Education
Emotional Support
Advocacy
Referral Checklist
Family carer is caring for an individual with a primary diagnosis of mental illness?
*
- required
Yes
No
Relationship to the person you are caring for
*
- required
[Choose One]
Parent
Partner
Child
Friend
Referral has been discussed with family carer.
*
- required
Yes
No
Does the family/carer live within the Hunter New England Region
*
- required
Yes
No
Mandatory field(s) marked with *
X