JALNGANGURRU HEALING REFERRAL FORM

JALNGANGURRU HEALING REFERRAL FORM

KALACC Traditional Healing Practices Pilot (THPP)
Contact details
Name
Date of birth

MonthDayYear
Date
Home address
Postal address (if different from home address)
Phone
Email
example@example.com
Personal information
Gender

MaleFemaleOther
Aboriginality

AboriginalTorres Strait IslanderBothOther
How did you find out about this project?
Aboriginal information

Please answer the following questions if you are Aboriginal and / or Torres Strait Islander
Language group (who is your mob and / or Aboriginal family?)
Skin group? (if you are unsure please skip this question)
Emergency Contact
Emergency contact name
Emergency contact phone
Emergency contact email
example@example.com
Emergency contact home address
Completing this form means you are interested in seeking cultural (traditional) healing practices, including mabarn healing. In order to find you the best healer and the best healing practice, please tell us about the type of problem you are seeking healing for.
What needs healing?
Spiritual harm (bilurr)

Spiritual harmPhysical injuryIllnessOther
Please specify your answer e.g. what body part? Did you have a disagreement with someone / family group? Or, are you simply seeking traditional healing for wellbeing purposes?
Please rate how bad your pain / issue is from 1 (minor) to 10 (major)
Are there other troubles / issues we should be aware of?
Where have you been recently (i.e. where have you travelled)?
Medical Information
Do you have any medical conditions the healer should be aware of? If so please provide details
Are you currently receiving medical treatment? If so, please provide details including any medication you are taking
Do you or have you had COVID19?

YesNo
If you answered yes above, please provide further information including when you last tested positive for COVID10
Are you vaccinated against COVID19?

Yes - one doseYes - two dosesYes - three dosesYes - four dosesNo
Please note that you may be required to do a Rapid Antigen Test (RAT) before seeing a healer, and we may ask that you provide proof of COVID vaccinations.
Research consent
With your consent, you may be confidentially contacted by a researcher from the Nulungu Research Institute some time after the traditional healing has occurred. The information retained will be stored confidentially and will only be used publicly for reporting purposes, no names or identifying details will be made public. Please select 'yes' if you consent to being contacted.

YesNo
Date

MonthDayYear
Date
Signature

Clear
Referrals are managed by the Jalngangurru Healing Coordinator Petrine McCrohan at healing@kalacc.org.au or 0457 209 306. For further information about the service, contact KALACC Operations Manager on operations@kalacc.org.au.
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JALNGANGURRU HEALING REFERRAL FORM

Contact details

Personal information

Aboriginal information

Emergency Contact

What needs healing?

Medical Information

Research consent