Clone of ILC 1:1 capacity building referral form

IFCB Participant Referral Form

Hastings Neighbourhood Services: Individual & Family Capacity Building Program
Please note that the IFCB program is not funded to facilitate NDIS or DSP applications. The IFCB team may however, assist in the process if deemed necessary through our internal assessment process.

IFCB can offer 1:1 support for an individual or family, to identify barriers, build strategies to overcome those barriers, build skills for independence and community engagment. We can develop group programs and peer support opportunities that support life stage transitions. If this is what you are looking for, please complete the form below and a team member will contact you shortly.
Full Name

First NameLast Name
Phone Number
Format: (000) 000-0000.
E-mail
example@example.com
DOB:

MonthDayYear
Date
Gender:
Residential Postcode:
Referred By:
Name and Organisation
Referrer Contact Details:
Mobile and email address
Personal Information

Please select Yes or No (if you a service referring a client, please answer to the best of your knowledge)
Do you identify as living with a disability?
1. If yes, please explain your diagnosis below.
Are you currently receiving any formal or informal supports?
1. If yes, please list the supports below.
Do you care for any children or family members living with a disability?
1. If yes, please list the individuals name, age and diagnosis below.
Would you be willing to work 1:1 with a peer support worker to develop goal plans and receive support?
Family & Household Context
1. If we visit you at home, who would we meet? (please include ages and relationship to you)
2. Do you have any caring responsibilies that you are finding challenging? If yes, please describe your role and what you find challenging
4. Are there any upcoming transition points for your family that are causing you to feel unprepared or unable to adequately support yourself / child / family member?
Eg: transitioning from child care to primary school, primary school to highschool or highschool to employment / higher education. Further examples of transition points include: moving out of home to live independently, starting a relationship or entering employment.
Goals & Outcomes
1. What barriers are impacting your ability to support yourself, your child, or a family member living with disability?
Eg: communication barriers, sensory processing, overstimulation, behaviour management, lack of service knowledge, finances, transport etc)
2. What support would you like to receive from the IFCB team?
Eg: help navigating and understanding which services would be suited to your situation, help to find accepting and supportive education / employment options, support in setting up routines etc.
3. What would a positive outcome look like for you and your family?
Which of our 5 locations would you like to access services from?
Would you be interested in attending any of the IFCB skills workshops?
Would you be interested in attending any of the IFCB information sessions?
Would you be interested in attending any of the IFCB peer support groups?
Is there a specific topic that IFCB could run a skills workshop or information session on that you believe would benefit the community?
Help us prepare for your visit. Do you have specific support needs, like:

Other
Was this form completed by someone other than the participant?
Do you have permission to sign on behalf of the participant?
Date

MonthDayYear
Date
Signature
Should be Empty:

IFCB Participant Referral Form

Personal Information

Family & Household Context

Goals & Outcomes