AmeCare - Referral Form

Referral Form

ABOUT THE PERSON BEING REFERRED

CONTACT DETAILS

SUPPORT NETWORK

A bit more about you...

Support Requirements

Risk Assessment Checklist

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Referral Form
What service are you looking for?*

NDIS Accommodation (long-term)NDIS Accommodation (short-term/respite)Support CoordinationPsychosocial Recovery CoachingOutreach & In-Home SupportBehaviour SupportPlan ManagementTraining & DevelopmentOther
Who is this referral for?*

MyselfFamily member or friendClient of my serviceOther
** If you would like an easy-read version of this form, click HERE
ABOUT THE PERSON BEING REFERRED
Name:*

First NameLast Name
Nickname/ Preferred Name:
Date of Birth (DOB)*

DayMonthYear
Date
Preferred pronouns:
Gender:*

FemaleMaleNon-binaryTransgenderIntersexPrefer not to respondOther
Relationship Status

SingleDomesticMarriedSeparated/DivorcedPrefer not to respondOther
Religion/ Spirituality:
Nationality:
Language/s:*
ATSI?*
Interpreter?
If Yes, please provide additional information:
Diagnoses & Medical Alerts*
CONTACT DETAILS
Mobile:*
Landline:
E-mail:*
example@example.com
How would you like us to contact you? (Tick all that apply)*

Phone CallVideo CallPost/LetterEmailSMS/Text MessageCommunicate with someone other than meOther
Current/ Last fixed address*
EMERGENCY CONTACT / NEXT OF KIN / LEGAL GUARDIAN
(the best person to contact in an emergency)
Name*
Relationship to you*
Contact Number*
Email
Are there other people or organisations involved in supporting you?

YesNo
SUPPORT NETWORK

(informal/formal connections e.g., financial administrator, current NDIS supports, plan nominee, family members, etc)
Name
Relationship to you
Contact Number
Email
Name
Relationship to you
Contact Number
Email
Name
Relationship to you
Contact Number
Email
Name
Relationship to you
Contact Number
Email
A bit more about you...
Relevant Goals*
These can be your NDIS goals and/or your own personal goals
Current accommodation status:

Private TenancySupported AccommodationHomeless/transientInpatient (clinical setting)Other
Funding Source*

Privately Funded (e.g., DSP, My Aged Care, TAC)NDISOther
Pension Reference #
Expiry (MM/YYYY)
Medicare Reference #
Expiry (MM/YYYY)
NDIS Reference #
Do you have any of the following supporting documents?

Risk AssessmentBehaviour Support PlanOther
If Yes, please attach them below:

Cancelof
Additional Information

E.g., funding or assessment details0/500
Support Requirements
What BEST describes the intensity/ capacity of supports you need:*

High IntensityDaily supportWeekly supportFortnightly supportLooking for respite, short-term, or transitional accommodationFlexible (e.g., supports as needed or requested)Other

Do you require assistance with medication administration?*

YesNo
If Yes, please provide any additional/relevant details:
Do you require/utilise mobility aids or sensory equipment? (e.g., wheelchair, walking frame, hearing aids, etc)

YesNo
If Yes, please provide any additional/relevant details:
Please include any additional details about the information collected...
Prompts: Did you answer "other" to any questions? Tell us a few things that are important to you (e.g., location, accessibility). What things help you feel comfortable, or make you feel uncomfortable? Or, any other details that can help us understand and support you to the best of our ability!

	No / minimal risk	Some / moderate risk	High risk / Active consideration
Self-Neglect
Personal Safety & Vulnerability (e.g., abuse or exploitation by others)
Substance use - drug
Smoking - tobacco
Substance use - alcohol
Wandering / Absconding
Choking, swallowing, or ingestion
Using electrical appliances
Self-Injurious Behaviours
Falling - with or without aids
Suicidal ideation / attempts

	No / minimal risk	Some / moderate risk	High risk / Active consideration
Domestic Abuse / Family Violence
Aggression or physical harm to others
Violence - staff
Violence - community/ general public
Threat to children / vulnerable people
Arson / fire-lighting
Sexual misconduct / offences
Stalking
Verbal intimidation / threatening behaviour
Capacity to Socialise
Property Damage
Theft
Navigating new / unfamiliar areas

	No / minimal concerns	Some / moderate concerns	Significant concerns / Active consideration
Personal Care (e.g., showering, dressing, hygiene)
Budgeting (e.g., groceries, bills, sudden expenses)
Cooking & Meal Preparation
Grocery / Personal Shopping
Laundry (e.g., washing, drying, putting away)
Transport (e.g., travelling in a car, public transport, using taxis)
Making & attending appointments
General domestic tasks (e.g., vacuuming, dusting, dishes)

	No / minimal concerns	Some / moderate concerns	Significant concerns / Active consideration
Self-Motivation
Capacity to Share
Impulse control/ recklessness
Orientation to time and place
Decision making capacity
Short-term memory
Long-term memory
Routine & troubleshooting
Non-Engagement with support
Cognition (e.g., following routine & procedures, troubleshooting)
Rapid change/s in physical or mental health
Exclusion or eviction from accommodation settings
Mobility (e.g., ascend/descend stairs)
Rapid change/s in physical or mental health
Emergency Response (e.g., use of 000 services)
Assistance with medication administration

	Yes	No
Have you ever been convicted or released on parole for criminal misconduct involving VIOLENCE?
Have you ever been convicted or released on parole for criminal misconduct involving STALKING?
Have you ever been convicted or released on parole for criminal misconduct involving SEX OFFENCES?
Are you or have you ever been listed on the VICTORIAN REGISTER OF SEX OFFENDERS (or equivalent in any State or Territory)?

Active Overnight

Night-time Sleepover

In-home Support

Community Access