Cause Victoria - Referral Form

Referral Form

ABOUT THE PERSON BEING REFERRED

CLIENT DETAILS

Support Requirements

Funding Sources

Who do we send invoices to?

A bit more information...

Risk Assessment Checklist

Supported Independent Living (SIL)Affordable Housing (AH)Respite or Crisis AccommodationShort-Term Accommodation (STA) - up to 30 daysMedium-Term Accommodation (MTA) - up to 90 daysAdditional Support (AS)Transitional Accommodation (TA)Other

MyselfFamily member or friendClient of my serviceOther

** If you would like an easy-read version of this form, click HERE

EMERGENCY CONTACT/ NOMINATED PERSON/ LEGAL GUARDIAN
(i.e., who needs to be contacted in an emergency?)

INFORMAL/FORMAL SUPPORT NETWORK
(e.g., case manager, plan nominee, next of kin)

Include their name, organisation, and contact details.

These can be your NDIS goals and/or your own personal goals

Risk AssessmentBehaviour Support PlanAllergy or Anaphylaxis Management Plan/sOther

E.g., funding or assessment details0/500

If you don't have a list of your current medications, please upload a photo of the medication description on the label of any medication containers (i.e., Webster-Pack, bottle, or canister).

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!

	>3 hours	>6 hours	>12 hours	>18 hours	>24 hours	<24 hours
Daytime
Evening
Overnight
Community Access

Privately Funded (e.g., DSP, My Aged Care, TAC)NDISOther

	DD/MM/YYYY
Start Date
End Date

Include their name, organisation, and contact details.

E.g., Driver's License, Passport, or Proof of Age card

I.e., the number next to your name on a Medicare Card

We ask you to provide this information so we can have a clear understanding of your support and safety needs. Answers will help with adequate quoting and funding for services provided.

Please note:

Answer honestly and transparently.
We work holistically, meaning we need to understand your strengths and weakenesses to be able to effectively implement supports.
We have strict policies around active substance use.
High risk considerations do not always affect our capacity to provide support.

Tick all relevant columns to indicate where there is a High, Medium, or Low risk of harm.

	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

	Current	History of	Frequency (i.e., how often?)	Substance (i.e., drug of choice)
Illicit Drug
Prescription Drug
Alcohol/ETOH
Tobacco/Nicotine
Other

	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
Been convicted or released on parole for criminal misconduct involving VIOLENCE?
Been convicted or released on parole for criminal misconduct involving STALKING?
Been convicted or released on parole for criminal misconduct involving SEX OFFENCES?
Been listed on the VICTORIAN REGISTER OF SEX OFFENDERS (or equivalent in any State or Territory)?

If you are submitting this form on behalf of someone else, please also include your relationship to the person being referred.

Active Overnight

Night-time Sleepover

In-home Support

Community Access