CLIENT REFERRAL

CLIENT REFERRAL FORM

To refer yourself or another person, please fill out the form below carefully. Please be detailed so as to best direct your referral to the most appropriate area. Your information is protected under the Privacy Act 1988.
Person making this referral:*
Name

First NameMiddle NameLast Name
Birth Date

DayMonthYear
Gender
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Mobile Number
Alternate contact
Guardian/Next of Kin
E-mail
example@example.com
Household Living Arrangements: (e.g. homeless, lives alone, with others, partner, children, parents)
Key reason for referral: (e.g. Peer Mentor required, Consulting, post-release from prison, AOD issues including drug of choice, frequency of use, relationship issues, court ordered)
Other Issues/Supports involved: (e.g. NDIS support coordinator, Assertive Outreach, Church, CMH Clinicians, mental health, legal, physical)

Explain as best possible referred clients current situation?

	PLEASE TICK
At-risk of offending
On Bail (Summary Offences)
On Bail (Indictable Offences)
In custody (Pre-trial/Pre-sentence)
In custody (Serving custodial sentence)
Custody (Post-release < 6 months until release)
Custody (Post-release < 12 months until release)
On a community-based order (Home detention bail/parole, ESO etc)

Identifies as

AboriginalTorres Strait IslanderAboriginal & Torres Strait IslanderNeither
DCS Number (if applicable)
NDIS Reference Number (if applicable)
Plan Manager (if applicable)
General Practitioner (if applicable)
Copy of NDIS Plan Provided (Yes / No)

YesNo

SERVICE LEVELS REQUESTED

	PLEASE TICK
Pro Bono Services (Fee-Free)
Sponsored Services (NDIS Funded/Third Party)
Basic Service Agreement + $3,000 - $6,000 per annum
Standard Service Agreement + $6,000 - $12,000 per annum
Enhanced Service Agreement + $12,000 - $25,000 per annum
All-Access Service Agreement + $25,000 - $50,000 per annum
Premium Service Agreement + $50,000 - $100,000 per annum
Exclusive Service Agreement + $100,000 >

SERVICE REQUESTS

	PLEASE TICK CIRCLE FOR SERVICE/S REQUESTED
Critical Outreach (24 Hours)Emergency Response Team Support
Peer Mentoring (Private)
Peer Mentoring/Community Participation (NDIS)
Specialist Interventions (AOD Harm minimisation)
Reintegration Services (Post-release)
Assertive Outreach (Support/Treatment resistant)
Social Media Training (Long-term incarcerated)
Employment Services/Skills
STA Respite
Court liaison services
Veteran Mentoring Program
Peer Mentor Training - Facilitated by ARCOFYRE®
Bespoke Consulting Services
Pre-Assessment (Home Detention suitability)
Criminal Justice advocacy
GET OUT OF JAIL FREE COFFEE CARD (Free coffee)
Community Reintegration (Housing Placement Support)
V.P.P. Program Review
ARCOFYRE® Certificate of Rehabilitation
Program co-design and management (External organisation only)
LEADER1 Leadership Development/Business Mentoring
Small Business Training
Remote Mentoring Program
Domestic Violence Response Service
Psychosocial Recovery Coaching
NDIS Access Request Support

BOOK INITIAL SERVICE CONSULTATION
APPOINTMENT LOCATION
Please enter any relevant information or any additional comments:
CASE MANAGEMENT NOTES:
Attachments:

Cancelof
What happens after we receive your information?: Once this referral is allocated to the relevant section, we will make contact to develop a Service Agreement. The agreement will need to be approved and signed before any services commence. We will work with the client and/or their decision maker to ensure the agreement meets their needs to organise the best supports available. Do you have any questions as we can have a staff member call you today to clarify any aspects of this client referral form?

YesNo
The purpose of this consent has been explained to me by staff from ARCOFYRE® and I give permission to have my personal information shared with ARCOFYRE® for the purposes of this referral. I understand that once received, ARCOFYRE® staff will contact me and also confirm with the referrer the outcome of this follow up. This consent for sharing of information will expire within one month of the referral being received. I understand that sharing my information with is done with the aim of ensuring I receive the best possible service.

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CLIENT REFERRAL FORM