Referral Form Step 1 of 2 50% Consent FormHas the person you support consented to this referral being made?(Required) Yes No Unfortunately, we will not be able to proceed if the person being referred has not consented to the referral. We encourage you to consider re-referring the person once consent is in place. Has the person you support consented for our team to contact them and yourself for the purpose of determining if this service is suitable for them?(Required) Yes No Unfortunately, we will not be able to proceed without yourself and the person being referred consenting to being contacted. We encourage you to consider re-referring the person once consent is in place.Has the person you support consented for minimal information about them to be collected and stored by ICLA for the purpose of determining if this service is suitable for them?(Required) Yes No Unfortunately, we will not be able to proceed without yourself and the person being referred consenting for your information to be collected and stored. We encourage you to consider re-referring the person once consent is in place.Referrer's DetailsName(Required) First Last Service/organisation(Required) Role(Required) Contact phone(Required) Contact email(Required) Are you referring this person from:(Required) Hospital (step down) Community (step up) What is your relationship to the person you support?(Required) Client/Patient Service Provider Support Coordinator Family Friend Other Please specify(Required) Applicant DetailsApplicant name(Required) First Last Applicant contact number(Required) Applicant email address(Required) Preferred method of contact?(Required) Phone call SMS Email Other Please specify: Does the person you are referring 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 Is the person you support currently experiencing or at risk of homelessness?(Required) Yes No Is the person you support 18 years of age or older?(Required) Yes No DemographicsApplicant 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 Applicant Date of Birth(Required) DD slash MM slash YYYY Do they speak another language other than English at home?(Required) No Yes Prefer not to say Please specify: Do they identify as culturally and/or linguistically diverse?(Required) No Yes Prefer not to say Please specify: Were they born in a country other than Australia?(Required) No Yes Prefer not to say Please specify: Do they identify as indigenous? Aboriginal Torres Strait Islander Both Aboriginal and Torres Strait Islander Neither Indigenous Identity not listed Prefer not to say What are their preferred pronouns?(Required) She/her He/him They/them Other Prefer not to respond Please specify: Do they identify as:(Required) Female Male Gender diverse Agender Gender not listed Prefer not to say Do they identify as part of the LGBTQI+ community?(Required) No Yes Prefer not to say Referral QuestionsDo they have someone who supports them 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 individual and their carer consent to these details being provided AND for the carer to be contacted in relation to this referral.Do they identify with any mental health diagnoses?(Required) No Yes Please specify: Are they on a Community Treatment Order (CTO)?(Required) No Yes Please specify: Do they identify with any physical health diagnoses or have any mobility issues?(Required) No Yes Please specify: Are they fully vaccinated against COVID-19?(Required) No Yes Have they presented to any Emergency Department in the past month?(Required) No Yes Prefer not to say Have they used non-prescribed drugs or alcohol in the last month?(Required) No Yes Prefer not to say Do they require support for decision making?(Required) No Yes Guardian details:Can they manage their own medications?(Required) No Yes Not applicable If they need to exit the program at any point during the 28 days, where do they plan to reside?(Required) Mailing address listed above Other address Please provide detailsWhat is happening in their life at the moment that you think PARC can help with?(Required)What are they hoping to achieve from a stay at PARC?(Required)Please provide any other relevant information regarding their application.(Required)
