Proveda Referral Form

The customer consents to this referral being made, or if under 16 years old, the carer/ guardian has consented? *

Yes No

Customer First Name *

Last Name *

Is the customer name an alias or pseudonym? *

Yes No

Date of birth *

Customer contact number(s) *

Customer contact email

Customer address *

Street *

Suburb *

State *

Postcode *

Gender *

MaleFemaleOther

Program calc

Are you 50 years or older? *

YesNo

Do you live within the Northern Sydney Health District? Suburbs in this district include Hornsby, Ku-ring-gai, Lane Cove, Mosman, North Sydney, Northern Beaches, Ryde, and Willoughby. *

YesNo

Based on the above answers you are not eligable for the Proveda Assisted Care and Housing – Hoarding and Squalor referral

Do have a Commonwealth Home Support Programme (CHSP) Assisted Care and Housing – Hoarding and Squalor referral code? *

YesNo

To be eligabile for the Proveda Assisted Care and Housing – Hoarding and Squalor Program you need to have a My Aged Care referrral code - follow these steps to register and apply:

Register with My Aged Care by calling 1800 200 422 or visit their website to apply for an assessment request assessment through My Aged Care for Commonwealth Home Support Programme (CHSP) Assisted Care and Housing – Hoarding and Squalor referral code, assessor will determine eligibility.

What type of accommodation do you currently reside in? *

Private residence (client or family-owned home)Private rentalPublic rental (Community Housing)Public shelter or transitional crisis/ emergency accommodation

Alternative Contact Person Name

Alternative Contact Person number(s)

Does the client reside in Northern Sydney Health district *

YesNo

Has the client consented to a referral? *

YesNo

Has the client experienced or is experiencing *

Attempted suicideSuicidal ideationNone of the above

Based on the above answer(s) your patient does not qualify for The Way Back (NSW) program.

For more information please visit our website www.proveda.com.au

1300 000 125 or thewayback@proveda.com.au

Which volunteer program would you like to refer to?

Compassionate ChampionsCommunity Mentoring ProgramCommunity Visitor SchemeAny volunteer program or unsure which program

Client country of birth

What is the main language spoken at home?

Employment status?

Full timePart timeN/A

Marital status?

SingleMarriedDivorced

Is the customer homeless?

YesNo

Is this the first time this GP has made a referral to the Proveda GP Social Work Program? (Previously Proveda/ProvedaGP Social Work Program)

YesNoUnknown

Presenting issues?

High or complex care needs requiring support from a range of community care providersCarer stress or burnoutDifficulty navigating and accessing support servicesRecent and/or recurrent hospitalisations due to care needsComplex family situation including family and domestic violenceAlcohol or substance abuseLoneliness and isolation

Does the customer have care needs that require support and assistance?

YesNo

The customer has been recently hospitalised and is at risk of being without support?

YesNo

Outline medical, health and/or mental health issues

Contact Person Name *

Contact Person Phone *

Contact Person Email *

How can the program best assist the customer? *

What is the customer's primary disability as accepted by the NDIS?

NDIS Number

Is the customer self managed or plan managed?

YesNo

Does their NDIS plan include a recovery coach?

YesNo

NDIS Plan Start Date

NDIS Plan End Date

The customer has chronic and/or complex health care conditions?

YesNo

Outline any co-existing issues (i.e. Drug & Alcohol, Housing, Finances, Legal, Social and Vocational Participation)

What was the reason for the customer's most recent hospital admission?

Outline any special considerations to be aware of in working with the customer ?

How many hospital admissions has the customer had in the last year?

List any other services involved

Local Government Area (LGA) that the referring GP Practice is located?***if the client is not located in any of these LGAs, they are not eligible for the service. If the client is located in the Hornsby, Ryde or Kuringai LGAs please refer to PCCS on 02 9477 8700 *

Is there any additional information or are there any risks we should be aware of? *

Referrer name *

Relationship to Customer *

Referrer contact number *

Referrer Organisation type *

How did you hear about Proveda? *

If this referral is being made by hospital or community mental health team please attach a copy of customer's safety plan

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Referring GP *

Professional completing form on behalf of GP

Name of referring Medical Practice *

Client veteran status: *

Is the client experiencing homelessness? *

Gender Identity: *

Pronouns:

Is an interpreter acquired? *

YesNo

Primary Diagnosis

Secondary Diagnosis

Current use of Alcohol and Other Drugs? *

History of Alcohol and Other Drugs? *

Nature and method of most recent suicide attempt

Do they have a recent/current suicide plan/method?

YesNo

Date of most recent suicide attempt

Did this attempt lead to current inpatient admission, or occur within the past 12 months?

YesNo

Has the client made previous attempts over their lifetime?

NoPrevious attempt/s made in the last 12 monthsPrevious attempt/s made within their lifetimeNot stated/inadequately descried

Is there any additional information (eg. history of violence or aggression) or are there any risks we should be aware of?

Is the client in hospital? *

YesNo

Anticipated discharge date *

Are there any additional referrals to be made?

Next of Kin *

NOK Phone Number *

NOK Email *

Referrer Name *

Referrer Phone Number *

Referrer Email *

Referring Organisation *

NSLHD Organisation *

Other Organisation details *

Referring Unit: *

Profession of Referrer: *

Please upload a copy of the Current Safety Plan

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