The Way Back NSW Referral Form

Has the client consented to a referral? *

YesNo

Does the client reside in the Northen Sydney Health district. *

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

Client First Name *

Client Last Name *

Is this name an alias or pseudonym? *

YesNo

Client Date of birth *

Contact Email *

Contact Phone number *

Client Address *

Street address *Street address line 2

Suburb *

State *

Postcode *

Country

Client country of birth *

Next of Kin Name *

NOK Phone Number *

NOK Email *

Client veteran status: *

Is the client experiencing homelessness? *

Gender Identity: *

Pronouns:

Does the client identify as any of the following? *

AboriginalTorres Strait IslanderBoth Aboriginal & Torres Strait IslanderCALD (Culturally and Linguistically Diverse)LGBTQI+None of the aboveUnspecified/ Undisclosed by client

Is an interpreter acquired? *

YesNo

Primary Diagnosis:

Secondary Diagnosis:

Current use of Alcohol and Other Drugs?

History of Alcohol and Other Drugs?

Medications:

AntipsychoticAnxiolyticsHypnotics and SedativesAnti-depressantsPsychostimulantsPlease tick if there has been a recent medication change

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?

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?

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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