Forensic Therapeutic Program referral form

Age:
Number
Forensic Therapeutic Program referral form

Including individuals subject to Community Orders/Parole
This form is for the use of professionals and 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/forensic-therapeutic-program. For security reasons, do not email this referral form directly to us.

This form is to be used for referrals to SASS' Forensic Therapeutic program.

Other referral forms are available from https://www.sass.org.au/make-a-referral;
- Adult Counselling program and Redress Support Service.
- General Children and Families Counselling Service.
- 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
- If the client is currently incarcerated, when is their expected release date:
- If the client is currently incarcerated, what area and/or address will they be released to:
  (e.g. Hobart, Devonport, West Coast)
- Has the client ever been charged or convicted with offences of a sexual nature?
  
  NoYes (provide details below)
- If yes, please specify:
  Date, year, sentence etc.
- 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 accessed SASS previously?
  
  YesNoUnknown
- 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
- 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 IslanderPrefer not to sayCulturally and linguistically diverse background
- Please specify:
  Cultural and linguistic background.
- 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:
- Is the client subject to any Family Violence Orders?
  
  YesNo
- If yes, please provide details including date of expiry and any exclusions/restrictions on areas/people:
  This information will help us assess for conflicts of interest.
- If the client is subject to a Community-based Order, please specify:
  
  Community ServiceCommunity Corrections OrderHome DetentionCourt Mandated Diversion and Drug Treatment OrderParoleOther
- Please provide Community-based Order details:
  E.g. offending type, sentence length, expected date of discharge, reporting obligations, restrictions (and/or a copy of their Order attached to this referral, below).
- Copy of any documentation that may be helpful such as criminal history, Order or psychiatric reports (only if available):
  
  This would help us support the client to manage the conditions of their Order.
  Cancelof
- If the client is currently in prison, where are they housed?
  
  Ron Barwick Minimum Security PrisonRisdon Prison ComplexMary Hutchinson Women's PrisonHobart Reception PrisonSouthern Remand CentreOther, please specify:
- Current sentence details:
  E.g. offending type, sentence length, earliest release date, parole eligibility date.
- Other (please indicate):
  E.g. on bail, pre-sentencing, charged but not convicted, transferring from juvenille justice, high risk of entering system.
- Has the client engaged in any mental health, rehabilitative, or other treatment programs/groups?
  
  NoYes, please specify:
- 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?
  
  YesNoUnknown
- Please provide any relevant information regarding sexual assault history if possible:
  E.g. historical, current, ongoing, single or multiple instances etc.
- Are there any safety issues for the client?
  I.e. threat of further sexual assault/abuse, etc
- What is the client’s support network?
- What are the client’s strengths/ current coping strategies?
- Are there any additional factors that have led to the client seeking a referral?
- Does the client need support to access SASS?
  E.g. disability, interpreter, support person, medical, cultural, anxiety/mental health, etc.
- 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 is the best time/days for SASS appointments?
- What are the preferred modalities for SASS appointments?
  
  Face to FaceVideo callPhone callCombination
- Does the client have reliable access to internet and technology?
  
  YesNo
- 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: