COMMUNITY CONNECTIONS PROGRAM

COMMUNITY CONNECTIONS
PROGRAM - REFERRAL FORM
To assist Open Support to process this referral, please complete all mandatory fields and attach any other relevant documentation. All referrals to the Community Connections Program must include either a signed or verbal client consent.

*Please note- referral form is not compatible with Internet Explorer web browser
Client Eligibility

The Community Connections program aims to support people to establish and maintain meaningful social connections within their community, leading to reduced social isolation and increased wellbeing. Social Connection Case Managers will assist individuals to identify social opportunities that may decrease social isolation and improve overall wellbeing. Opportunities for social connection may be directly provided by the Open Support’s Community Connections program or by other external service providers
Please tick all that apply:

The client is experiencing social isolation and/or lonelinessThe client is seeking to establish meaningful social connectionsThe client would like to improve their social skillsThe client would like to connect with their communityThe client is 18 years or older
Client Details
First and Last Name of client*

First NameLast Name
Preferred Name
Mobile Number
Please enter a valid phone number.
Home Number
Please enter a valid phone number.
Email
example@example.com
Preferred method of contact
Address*
Date of Birth*

DayMonthYear
Date
Gender*
Gender Description
Country of Birth*
Country of Birth - Other
Identifies as CALD?*
Languages spoken at home
Please hold "CTRL" + mouse click to select multiple options
Interpreter Required?*
Indigenous Status*
Identifies as LGBTQIA+?*

Emergency contact details
Emergency Contact Name

First NameLast Name
Emergency Phone Number
Please enter a valid phone number.
Emergency Contact Email
example@example.com
Emergency Contact Relationship to Client

Current client circumstances
Are there any Health issues?*
Description of Health Issues

0/1500
Are there any Mental Health Issues?*
Please add as much detail as possible to help us assist individual.
Description of Mental Health Issues

0/1500
Are there any Disabilities?*
Description of Disability

0/1500
Are there any Substance Use issues?*
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Description of Substance Use
Recent history of violence or aggression?*
Details of violence or aggression
Other relevant Information
Formal supports available?*
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Description of Formal supports*

0/1500
Informal Supports Available?*
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Description of Informal Supports

0/1500

Client consent

Referrers must confirm that the consumer understands and consents to the following:

The collection and use of the client’s personal information is to determine their suitability to participate in the Community Connections program. The client understands that an Open Support representative will contact them and may ask additional questions to further assess eligibility
Client consents to this referral*

Yes
Referrer Details

In referring this client, you agree that any information provided in relation to this referral is accurate to the best of your knowledge and that no information will be withheld by you that is necessary for ensuring Open Support can fulfil its duty of care to the client and meet its obligations to staff and volunteers.
Referrer Name*

First NameLast Name
Referrer Contact number
Please enter a valid phone number.
Referrer Organisation
Referrer Email*
example@example.com
Date of submission

DayMonthYear
Date
Should be Empty:

Amharic
Arabic
Bengali
Cantonese Chinese
English
French
German
Greek
Gujarati
Hausa
Hindi
Igbo
Indonesian
Italian
Japanese
Kannada
Laos
Mandarin Chinese
Marathi
Mongolian
Nepali
Odia
Oromo
Portuguese
Punjabi
Russian
Shona
Spanish
Swahili
Tamil
Telugu
Thai
Turkish
Urdu
Vietnamese
Yoruba
Zulu
Macedonian
Other