Referral Form Referral Form Referring Agency / Family Members / GRSI Staff – Client Details Name Pronouns Address Phone Date of Birth Aboriginal / Torres Strait Islander Yes No I understand that providing false or misleading information is a serious offence and can be grounds for dismissal from the rehabilitation programme. Client Signature (typed) Date Referring Agency / Family Members / GRSI Staff – Referrer Details Name Position Agency Phone Email Date of referral Client consented to this referral Yes No Emergency / Next of Kin contact person Phone Relationship to client Rehabilitation Treatment History Has the client previously been to a rehabilitation program? Yes No If yes, please provide details including the year of treatment, treatment provider and length of sobriety before relapse Drug History Substance Age started How often Alcohol Methamphetamine Cannabis / Synthetic Cannabis Heroin Ecstasy Tobacco Prescription Drugs (Tramadol, painkillers, Seroquel) Benzodiazepines (valium) Volatile Solvents (sniffing) Medical History General Medical History – including any diagnoses and treatment plans Any history of seizures or epilepsy? Yes No Date of last episode Has the client recently been hospitalised? Yes No If yes, please provide details, including the date of admission and what for Mental Health Does the client have a history of involvement with mental health services? Yes No Is the client currently receiving mental health treatment? Yes No Experiencing Symptoms of Severe Depression Severe Anxiety Bi-Polar PTSD Psychotic Disorder Eating disorder Personality Disorder ABI Intellectual Disability Please provide details regarding diagnosis, symptoms, insight, hospitalisation and treatment Please list all medical, health and welfare professionals involved in the client’s care – Service Provider / Contact Details Recommendation Other Presenting Needs Risk Issues Please comment on a history of ideation / behaviour to self-harm or harm others Legal History (Mandatory) Please list down the client's criminal history of a violent nature, such as sexual assault, aggression to staff and the outcome of court. Criminal / Violence History Court Outcome 1. Court Outcome 2. Court Outcome INFORMATION FOR REFERRING AGENCY / PRACTITIONER To be considered eligible for the service, potential residents must meet all the following criteria: Eligibility Criteria for residential rehabilitation: Male or Female and over the age of 18 years old (No couples allowed) The service reserves the right to request a medical clearance, Criminal History and/or urine samples before intake. For Mental health co-morbidity potential residents, the predominant presenting issue needs to be alcohol and other drugs. Community Mental Health also needs to be actively engaged in supporting the client. Potential resident is actively engaged with counselling and/or support services OR agrees to engage with an appropriate agency or service as soon as possible. Committed to abstinence for the duration of the program Exclusions: Acute mental health clients who are deemed unstable and who have the potential to place themselves and others at risk are not eligible to enter the service. Potential residents who have identified behavioural or legal issues that have the potential to impact their stability or safety of others as a resident and the capacity to engage effectively within the GRSI programme timetable are not eligible to enter the service. Outreach service is available to anyone with alcohol and/or other drug and/or mental health issues that require extra support to address. Outreach can provide a case management service and put appropriate referrals in place to ensure maximum support is acquired. Consent to Release Information Before the assessment is agreed upon, the referring service or agency must provide a signed consent form for the release of information. Appointment for Eligibility Assessment The referring agency or self-referred client can email admin@grsi.org.au, or if they wish to speak to staff, they may contact the GRSI office at 08 9021 4732. Referring agencies and/or clients will be contacted within 24 hours to arrange an appointment to complete an assessment. This process will further assess the client's eligibility for the service and identify further assistance they may require. Submit Referral Form
