SASS Adult referral form

Age:
Type a question
Adult referral form

Adult Counselling program and Redress Support Service
This form is for the use of professionals or service providers. For self-referrals please phone us (03) 6231 0044 during business hours for direct support from our friendly team.

If you have experienced sexual violence or harm in the past 7 days, please call the SASS 24/7 Helpline (1800 697 877) for immediate information and support.

Once completed, save this referral form to your files, then upload via the secure PDF upload https://www.sass.org.au/adult-counselling-program-and-redress-support-service. For security reasons, do not email this referral form directly to us.

This form is to be used for referrals to SASS' Adult Counselling program and Redress Support Service.

Other referral forms are available from https://www.sass.org.au/make-a-referral
- General Children and Families Counselling Service.
- Forensic Therapeutic program.
- Prevention, Assessment, Support and Treatment of harmful sexual behaviours program.
SASS has eligibility criteria for all programs. Thank you for providing as much detail as possible. The information you share helps the intake team manage demand for our services. If you are unsure whether your referral is appropriate, please contact us to discuss.
Date of referral:

DayMonthYear
Date
Referring person or agency:
Referrer relationship to client:
Referrer email:
example@example.com
Referrer phone number:
Please enter a valid phone number.
Has the client indicated they are wanting support regarding their experience of sexual harm?

YesNo
Has the client consented to this referral being made?

YesNo
Has the client experienced or witnessed Family Violence?

YesNoUnknown
When responding to this referral, who should we first make contact with?

ReferrerThe client
Has the client accessed SASS previously?

YesNo
Is the client a participant of the National Redress Scheme:

YesNoUnknown
How did the referrer/the client hear about SASS?

Child Safety ServiceAdvice and Referral LineInternet SearchSocial MediaInterstate serviceMedical Practitioner/ Health ServiceNDIS/Disability ServiceNGO servicePolice/Legal/JusticePsychologist/ CounsellorRedress Scheme/ KnowmoreIs your referral a result of contact with Primary Care Family and Sexual Violence Support?Other
- Client name:
  
  First NameLast Name
- Date of Birth:
  
  DayMonthYear
  Date
- Gender:
  
  FemaleMaleTransgenderNon-binaryPrefer not to say
- Preferred pronouns:
  
  He/Him/HisShe/Her/HersThey/Them/TheirsPrefer not to sayOther (please specify)
- Cultural identity:
  
  NoneAboriginal and Torres Strait IslanderAboriginalTorres Strait IslanderCulturally and linguistically diverse background, please specify:
- Does the client have a disability, or any other mental and/or physical health presentations?
  
  YesNoPrefer not to sayNot known
- If yes, please specify:
- Does the client have any literacy limitations:
  
  Reading difficultiesWriting difficultiesUnable to read or writePrefer not to sayNot knownOther, please specify:
- Have any of the following taken place:
  
  Police InvolvementForensic Medical ExaminationOther:
- If yes, is this:
  
  CurrentHistoric
- Phone Number
  
  Area CodePhone Number
- Is this a safe number to receive calls, texts and voice messages?
  
  YesNo
- Email
  example@example.com
- Does anyone else have access to this email account that may compromise the client’s privacy?
  
  YesNo
- Preferred form of contact
  
  PhoneEmail
- Residential address
  
  Street Address
  
  Street Address Line 2
  
  Town/SuburbState
  
  Post Code
- Is it safe to send hard copy mail to this address?
  
  YesNo
- Postal address
  
  Same as residential address
- Street Address
  
  Street Address Line 2
  
  Town/SuburbState
  
  Post Code
- Is it safe to send hard copy mail to this address?
  
  YesNo
- Who else resides with the client?
- If the client has a significant support person or carer, please provide their details below.
- Name
  
  First NameLast Name
- Relationship to client:
- Phone:
  
  Area CodePhone Number
- Email:
  example@example.com
- Is the primary contact aware of all information on this referral form?
  
  YesNo
- Will this person be organising the appointments at SASS?
  
  YesNo
- What are the client's key difficulties at present?
  (I.e., mental health; self-harm; drug & alcohol; homelessness; depression; hallucinations; flashbacks; self-regulation; delusions; etc. Please Include frequency, duration and severity of symptoms/behaviours)
- Is this a first disclosure?
  
  YesNo
- Please provide details of the sexual assault history if possible:
- Did the abuse include any technology-facilitated abuse? If yes, did it involve:
  
  Coercive controlImage basedOnlineOnline and image basedStalking/monitoringOther (please describe)
- Are there any safety issues for the client?
  (I.e. threat of further sexual assault/abuse, etc)
- What is the client’s support network (both social and professional)?
- What are the client’s strengths/ current coping strategies?
- Are there any additional factors that have led to the client seeking a referral?
- Are there any indications for safety issues for SASS workers with the client?
  (e.g. anger issues, psychosis, client views worker as threat etc.)
- What are the best times/days for SASS appointments?
- What are the preferred modalities for SASS appointments?
  
  Face to FaceVideo callPhone callCombination
- What support is the client hoping to access?
  
  Trauma specific therapeutic support related to prior sexual harmRedress SupportUnsureOther, please specify:
- Does the client prefer a counsellor of a particular gender? (We will do our best to accommodate preferences wherever possible.)
  
  FemaleMaleEitherUnknown
- Referral taken by (SASS representative):
- What is identified as the primary need for support?
  
  Brief interventionComprehensive counselling serviceGroup / Wellbeing ProgramRedress Scheme
- Should be Empty: