Referral Form - Phoenix House

Hidden

Date of Referral*

Reason For Referral*

Questionnaire

NDIS Referral
Mental Health Care Plan
Is There A Current DVO In Place?
Is There A Current Parenting Plan In Place?
Is There A Current Family Law Court Order In Place?
Are There Any Disability / Physical Needs?
Is This A Youth Justice Client?
Does The Client Require An Interpreter?
Is It Safe To Send Mail To This Address?
Is It Safe To Send SMS Reminders To This Phone Number?
Has The Client Attended This Service Before?

Previous Counsellor

How Did You Hear About This Service?

Enquiry Type*

Child Client (0 - 15 Years)
Adult Client (16 Years & Above)

Client Information

Self-Referral*

Yes
No

Adult Clients Name*

First Last

Adult Clients Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Adult Clients Contact Number

Is it safe to send SMS reminders to this number?

Yes
No

Adult Clients Email Address

Is it safe to send email reminders to this address?

Yes
No

Bumble Bee's Program Referral*

Yes
No

Childs Name*

First Last

Date Of Birth*

Gender*

Male
Female
Questioning

Cultural Needs

Aboriginal
Torres Strait Islander
CALD

School

Referrer Information

Referrer Name*

First Last

Relationship To Client*

Referrer Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Referrer Contact Number*

Referrer Email Address*

Is this a Self-Referral?

Yes
No

Have you received the vaccination for COVID-19?

Yes
No

Cultural Information

Aboriginal
Torres Strait Islander
Both
Neither
CALD

Would you like to be assisted by our Aboriginal Cultural Liaison Officer?

Yes
No

Do you require an interpreter?

Yes
No

Is there a current DVO in place?

Yes
No

Is there a current Parenting Plan in place?

Yes
No

Is there a current Family Law Court Order in place?

Yes
No

If yes to any of the three above questions, please provide a copy.

Max. file size: 2 MB.

Have you attended this service before?

Yes
No

If yes, previous counsellor:

If no, how did you hear about our service?

Mental Health Care Plan?

Yes
No
Unsure

Medicare Number:

Client Reference:

Expiry Date:

Reason for Referral:

Note:

Please be aware that Phoenix House will only retain the referred persons details on file. All other information regarding another person’s information will be suppressed from this referral and is not permitted into case notes without their permission. This is to keep within the Privacy Act 1988.