AmeCare - Referral Form

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Referral Form
What service are you looking for?

Other
Who is this referral for?

Other
** 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:

Other
Relationship Status

Other
Religion/ Spirituality:
Nationality:
Language/s:
ATSI?
Interpreter?
If Yes, please provide additional information:
Diagnoses & Medical Alerts
CONTACT DETAILS
Mobile:
Format: 0000 000 000.
Landline:
Format: (00) 0000 0000.
E-mail:
example@example.com
How would you like us to contact you? (Tick all that apply)

Other
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?
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:

Other
Funding Source

Other
Pension Reference #
Expiry (MM/YYYY)
Medicare Reference #
Expiry (MM/YYYY)
NDIS Reference #
Do you have any of the following supporting documents?

Other
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:

Other

Do you require assistance with medication administration?
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)
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!

Rows	1:1	1:2	1:3	1:4	1:5	2:1
Daytime
Evening
Active Overnight
Night-time Sleepover
In-home Support
Community Access

Rows	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

Rows	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

Rows	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)

Rows	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

Rows	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)?

Referral Form

ABOUT THE PERSON BEING REFERRED

CONTACT DETAILS

SUPPORT NETWORK

A bit more about you...

Support Requirements

Risk Assessment Checklist