Referral Form – Carer Support Program

Referral Form – Carer Support Program
Referral Form – Carer Support Program
TEAMhealth Carer Support Program Provides:
Flexible support options for carers of people with mental illness whose health and wellbeing or other impediments
are impacting on their ability to provide care.
Services focus on:
 Providing a range of education and support to assist carers to continue providing care, and/or improve their
health and wellbeing through social and economic participation in the community.
 Provide information about other appropriate services and support to access services, to assist carers to
continue providing care.
 Reduction of stigma and discrimination to ensure that, carers are better able to sustain their caring roles.
Name:
Address:
Carer details:
DOB:
Gender:
 Male  Female
 Other
Telephone:
Mobile:
Email address:
Are you:
Aboriginal:
 Yes
Torres Strait Origin:  Yes
Country of Birth:
 No
CALD:
 Yes
 No
 No
Non Indigenous:
 Yes
 No
Main Language spoken at home:
Interpreter Required:
 English  Other
 Yes
 No
(list):_________________
(list):_________________
Do you feel that the care you provide is impacting on your own physical or mental health?
 No  Yes  Sometimes
If so what do you feel is impacting on your physical or mental health?
What do you feel would support you to help maintain or improve your own health and wellbeing?
Do you require urgent assistance or support, including being at risk of homelessness?  No
If so what supports do you require?
Are you a young carer?
 No  Yes
Are you a self-carer?
 No  Yes
This Form is uncontrolled once printed. Refer to TEAMhealth T Drive for current version.
 Yes
Are you an older parent carer?
 No  Yes
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TEAMhealth Referral Form Carer Support 118 - OPR
Are you currently working?
  Full time employment
 Unemployed
 Part time employment
 Other (please explain)
Do you receive a Centrelink benefit?  No
If so what benefit do you receive?
 Casual employment
 Yes
Do you receive support/assistance from family or friends?  No
If so, what does this involve?
 Yes
 Sometimes
Are you receiving support/assistance from other services?  No
If so, what services are you involved with?
 Yes
 Sometimes
Have you previously received support/assistance from other services?  No
If so, what services where they?
 Yes
Care Recipient Details
Do you care for a person with a diagnosed mental illness?  No
If so what is the diagnosis of the person you care for:
 Yes
In a typical week, what do you do to support the person you care for?
 Transport
 Emotional support
 Medication administration
 Housework
 Financial management
 Assist to attend appointments
 Meal preparation
 Shopping
 Other: ______________________________
In a typical week, how much time to you spend caring?
 Less than 20 hr/week
 20 - 40 hrs/week
 40+ hrs/week
Does the person you care for receive support/assistance from other services?  No
If yes, what services are they involved with and what does this support look like?
 Yes
Does the person you care for have Guardianship/Trustee or Community Management Orders in place?
 No  Yes
If yes, what does this look like?
Do you get paid a wage or salary to provide care for the person with a mental illness?  No
This Form is uncontrolled once printed. Refer to TEAMhealth T Drive for current version.
 Yes
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TEAMhealth Referral Form Carer Support 118 - OPR
Person referring or referral agent details
 I confirm that as a carer I have consented for this referral to occur.
 I confirm that as a carer I have consented to the sharing of information between TEAMhealth and the referring
agency for referral purposes.
(please note that a referral cannot be accepted without a carers consent)
Carer name:
Signature/s:
Date:
Person referring (if other than carer):
Signature:
Date:
Organisation:
Telephone:
Email address:
Please include any additional information and attach separate document/s as required
This Form is uncontrolled once printed. Refer to TEAMhealth T Drive for current version.
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