Referral Form Step 1 of 2 50% Consent FormDo you consent for our team to contact you if we need more information to determine if this service is suitable for you: Yes No Unfortunately, we will not be able to progress with your referral without you consenting to being contacted. We encourage you to consider re-referring yourself if you are able to provide this consent in future.Do you consent for minimal information to be collected and stored by ICLA so we can determine if this service is suitable for you:(Required) Yes No Unfortunately, we will not be able to progress with your referral without you consenting for your information to be collected and stored. We encourage you to consider re-referring yourself if you are able to provide this consent in future.Applicant DetailsYour name(Required) First Last Your contact number(Required) Your email address What is your preferred method of contact?(Required) Phone call SMS Email Other Please specify Do you have a care coordinator (also known as a case manager) through the South East Sydney Local Health District – e.g. The Euroa Centre, The Maroubra Centre, St George Mental Health Service, Sutherland Mental Health Service, etc.(Required) Yes No Are you currently experiencing or at risk of homelessness?(Required) Yes No Are you 18 years of age or older?(Required) Yes No DemographicsYour Address(Required) Street Address City State Post Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Date of Birth(Required) DD slash MM slash YYYY Do you speak another language other than English at home?(Required) No Yes Prefer not to say Please specify: Do you identify as a culturally and/or linguistically diverse?(Required) No Yes Prefer not to say Please specify: Were you born in a country other than Australia?(Required) No Yes Prefer not to say Please specify: Do you identify as indigenous? Aboriginal Torres Strait Islander Both Aboriginal and Torres Strait Islander Neither Indigenous Identity not listed Prefer not to say What are your preferred pronouns?(Required) She/her He/him They/them Other Prefer not to respond Please specify: Do you identify as:(Required) Female Male Gender diverse Agender Gender not listed Prefer not to say Do you identify as part of the LGBTQI+ community?(Required) No Yes Prefer not to say Self Referral QuestionsDo you have someone who supports you regularly i.e. a family member, close friend or other informal carer?(Required) No Yes If yes, please only provide carer name and contact details ONLY if the carer consents to these details being provided AND for the carer to be contacted in relation to this referral.Do you identify with any mental health diagnoses?(Required) No Yes Please specify: Are you on a Community Treatment Order (CTO)?(Required) No Yes Please specify: Do you identify with any physical health diagnoses or have any mobility issues?(Required) No Yes Please specify: Are you fully vaccinated against COVID-19?(Required) No Yes Have you presented to any Emergency Department in the past month?(Required) No Yes Prefer not to say Have you used non-prescribed drugs or alcohol in the last month?(Required) No Yes Prefer not to say Do you require support for decision making?(Required) No Yes Guardian details:Can you manage your own medications?(Required) No Yes Not applicable If you need to exit the program at any point during the 28 days, where do you plan to reside?(Required) Mailing address listed above Other address Please provide details:What is happening in your life at the moment that you think PARC can help with?(Required)What are you hoping to achieve from a stay at PARC?(Required)Please provide any other relevant information regarding your application.
