Referral Form
Agency or self - to Marrin Weejali
Who is submitting this form?
*
Referral Agency
Client
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Referrer Details
Date of Referral
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-
Day
-
Month
Year
Date
Referrer
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First Name
Last Name
Contact Number
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Email
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Service Name
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Office Location
Has the client consented to this referral & information sharing with Marrin Weejali?
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Yes
No
Before you continue....
By continuing with this referral for a prospective client you understand that Marrin Weejali requires the referring agency to provide detailed reasons for the referral. Marrin Weejali cannot accept this referral without the client's consent and full cooperation. The client must also agree to the reasons recorded for this referral and be willing to participate in counselling and programs.
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Client Details
Date of Referral
*
-
Day
-
Month
Year
Client name
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First Name
Last Name
Contact Number
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Gender
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Male
Female
Other
Date of birth
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-
Day
-
Month
Year
Date
Identity
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Aboriginal
Torres Strait Islander
Other
Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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Further information
Substance Misuse & Addictions
Have you been directed to attend Marrin Weejali by any of the following services?
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DCJ Community Corrections / Parole Officer
DCJ Child Protective Services
Court
General Practitioner
Job Network
No
Other
Is this referral related to addiction (including gambling)?
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Yes - drug, alcohol and/or gambling addictions
No
Please give specific details regarding the addictions (including reasons and circumstances).
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Substance 1
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Drug, alcohol or gambling issues
Date last used?
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-
Day
-
Month
Year
Are there any other substances of concern?
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Yes
No
Substance 2
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Drug, alcohol or gambling issues
Date last used?
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-
Day
-
Month
Year
Are there any other substances of concern?
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Yes
No
Substance 3
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Date last used?
*
-
Day
-
Month
Year
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Further Information
Substance Misuse & Addictions
Any previous treatment for addictions?
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Yes
No
Currently on the methadone program?
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Yes
No
Currently on the buprenorphine (BUP) program?
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Yes
No
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Further Information
Mental Health & Medications
Currently taking regular prescribed medication for mental health or pain management? (including medicinal marijuana)?
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Yes
No
Medication 1 (name and dosage)
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What is this medication prescribed for?
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Any other prescribed medication?
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Yes
No
Medication 2 (name and dosage)
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What is this medication prescribed for?
*
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Further Information
Loss & Grief
Is this referral related to loss and grief?
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Yes
No
Please give specific details regarding the loss and grief (including reasons and circumstances).
*
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Further Information
Social & Emotional Wellbeing
Is this referral related to social and emotional wellbeing?
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Yes
No
Please give specific details regarding the social and emotional wellbeing issues?
*
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Further Information
Mental Health
Is this referal related to mental health?
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Yes
No
Please give specific details regarding the mental health issues (including reasons and circumstances).
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Mental Health Diagnosis
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Is this diagnosed mental health condition managed?
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What support are you hoping to receive for this condition from Marrin Weejali?
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Are there any other mental health diagnosis?
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Yes
No
Mental Health Diagnosis 2
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Is this diagnosed mental health condition managed?
*
What support are you hoping to receive for this condition from Marrin Weejali?
*
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Further Information
Mental Health
Suicide Attempts?
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Yes
No
Number of attempts
*
Date of last attempt
*
-
Day
-
Month
Year
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Further Information
Mental Health
Self Harm Attempts?
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Yes
No
Number of attempts?
*
Date of last attempt
*
-
Day
-
Month
Year
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Further Information
History of Violence
Is there a history of violence?
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Yes
No
Please provide further information regarding the violence.
*
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Further Information
History of Sex Offences
Is there a history of sex offences?
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Yes
No
Please provide further information regarding the sex offence.
*
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Further Information
Legal Issues
Are there any legal issues ?
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Yes
No
Outline the details of the legal issues or offences.
*
Outline any relevant orders/conditions related to the legal issue(s).
*
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Further Information
Apprehended Violence Order
Are there any current AVOs?
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Yes
No
What AVO type?
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Type 1
Type 2
Perpetrator (failure to provide these details will delay the referral being processed)
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First Name
Last Name
Protected Person (failure to provide these details will delay the referral being processed)
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First Name
Last Name
Please outline the details/conditions of the AVO.
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Any other current AVOs?
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Yes
No
What AVO type?
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Type 1
Type 2
Perpetrator (failure to provide these details will delay the referral being processed)
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First Name
Last Name
Protected Person (failure to provide these details will delay the referral being processed)
*
First Name
Last Name
Please outline the details/conditions of the AVO.
*
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Referral Completed
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Please upload any other documentation that will support this referral.
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