OUTREACH REFERRAL FORM PHAMS, PIR, NDIS, WA NDIS & ISC BELMONT

Transcription

1 PHAMS, PIR, NDIS, WA NDIS & ISC BELMONT 1

2 COMMUNITY OUTREACH SERVICES Partners in Recovery (PIR) Partners In Recovery is a government service directed by a team of respected agencies from different sectors, including Medicare Locals and Mental Health organisations. Richmond Wellbeing is the only NGO run PIR service in Australia. The PIR service works to support those who experience mental distress on their journey to recovery by connecting them to the right supports be they traditional or contemporary. The PIR service provides care coordination through connecting Network Members and the consumer to provide wraparound services. Through a collaborative system that fully involves the individual, agencies, service providers, families and carers, consumers engaging our service can plan a personalised journey that leads them toward recovery - that is in pursuing a good life (whatever that means to them). Finding services and supports to enable mental health recovery can be difficult in an age where recovery services are new. There is a myriad of services available, but trying to access those services which enable recovery can be overwhelming. Our team can assist you to find your way. Utilising the PIR service enables people to access an array of services that are available in their local community with the support of a support facilitator and have those services coordinated, so that each of *the person s needs are addressed. Personal Helpers and Mentors service (PHaMs) The PHaMs service assists people aged 16yrs+, who are experiencing severe distress to embark on a journey of recovery. In a coaching style support relationship, we work alongside people to dream, plan and do. Our staff work in person-cantered ways to facilitate self-empowerment by providing holistic support. The Richmond Wellbeing PHaMs services operate in the Bentley & Midland/Guildford areas. Integrated System of Care (ISC) Belmont ISC Belmont is funded by WAPHA to work with people from culturally and linguistically diverse (CaLD) communities to support social and emotional wellbeing. This program provides shortterm assistance and referral pathways for long-term support to people who experience mental health issues and alcohol and other drug (AOD) problems. This program also provides opportunities for capacity building to the CaLD community. NDIS / WA NDIS NDIS is a service that endeavours to provide individualised support for people with an ongoing mental health diagnosis. NDIS takes a person-centred strength based approach, working with participants, their families and carers to develop an individualised plan. NDIS aims to connect participants with their community, and mainstream supports help participants pursue their goals and aspirations to participate in everyday life. NDIS and WA NDIS are both the NDIS, but are available is different areas of Western Australia. Please visit our website at to find out which scheme you can apply for. Richmond Wellbeing is able to assist in applying to NDIS or WA NDIS, support co-ordination of an existing plan, and/or service delivery. More information on each of these services in available on our website If you require assistance in selecting the right service, please contact our Intake Officer at intake@rw.org.au or

3 REFERRER DETAILS Name: Postal Address: Phone: Agency / Position: Postcode: APPLICANT TO COMPLETE 1. Your Details First Name: Preferred Name: Family Name: Gender: Male Female LGBTIQ+ Other Date of Birth: Address: Phone: Mobile: Postcode: Aboriginal: Yes No Torres Strait origin: Yes No Culturally and Linguistically Diverse: Yes No Country of Birth: Main Language spoken: English Other: Interpreter required: Yes No Visa Status: Living Situation: Living Independently Living with family member/carer Homeless Other: Marital Status: Single Married Separated Divorced Widowed Defacto Children: Yes No Occupation: Source of Income: Age Pension Carer Allowance Disability Pension Family Assistance Youth Allowance Other (please specify): Department of Veteran s Affairs Unemployment Paid work Hold a DVA Card? Yes No If yes, what type? Gold White Other 2. Contacts Nominated support person (Next of kin / Alternative contact) Name: Relationship: Do you have a Case Manager? Yes No Name: Do you have a guardian? Yes No Name: 3

4 Do you have a Public Trustee? Yes No Name: Do you have a GP? Yes No Name: Which of the above is your preferred contact? Support Person Case Manager 3. Support and Areas of Need Service you are seeking: Existing NDIS Plan: Yes PIR PHaMs No NDIS WA NDIS Public Trustee NDIS Plan Number: ISC Belmont ROS (internal) Current diagnosis / disability: Yes No If yes, please provide details. GP (Attach plan) Currently receive support from a service: Yes No Where from: Previously applied for Richmond Wellbeing: Yes No Are there recovery steps you are working towards: Yes No Can you share them? Are there some specific areas you would like support to access i.e. education, employment, recovery planning, navigating life problems, things around the house? What has helped you in your recovery thus far? What are you passionate about? 4. Health and Wellbeing 4.1 Any mental health issues you currently receive treatment or support for? Yes No If yes, when did you first receive treatment/support for this? 4

5 4.2 Any physical health concerns you currently receive treatment for? Yes No If yes, how long have you received treatment for this? 4.3 Describe how your answers from Questions 4.1 and 4.2 impact your life. Do you have any legal issues we need to know about? (E.g. outstanding charges, convictions or a community treatment order) Yes No If yes, please provide details: Do you have any Alcohol or Drug issues? Yes No If yes, please provide details: Are you linked in with any Alcohol or Drugs services? Yes No 5. Consent I consent to the disclosing of my personal and health information to Richmond Wellbeing for the purpose of assessing my eligibility for receiving recovery support services. Signature: Date: * If Guardian, provide a copy of your Guardian Order issued by the State Health Tribunal. PLEASE COMPLETE FORM & RETURN TO RICHMOND WELLBEING F (08) E intake@rw.org.au Richmond Wellbeing Inc. ABN: Charitable Collections Licence No: P: PO Box 682, Bentley WA 6982 T:

6 Richmond Wellbeing PO Box 682, Bentley, WA 6982 T (08) F (08) E 6