Resource Options & Support for Carers Referral
Referrer Details
Name
*
Date of referral
Referrer agency
*
Email
*
Phone
*
Follow up referral with
*
Urgency
Not urgent
Urgent
Confidentiality & Privacy Agreement
Has the Carer or Parent (if Young Carer) given permission for the referral to be made to ROSC?
*
Yes
No
Has the Carer or Parent (if Young Carer) given permission for information provided to ROSC to be disclosed to Government departments and other agencies?
*
Yes
No
If yes, consent provided
by carer
by parent
by other
If other, please provide details
Carer details
First name
*
Last name
*
Preferred name
Gender
*
Male
Female
Other
Date of birth
Please select the option that is the most appropriate. Note that no diagnosis is necessary for a referral
*
The carer provides care for a person with a primary diagnosis of mental illness
The carer provides care for a person who has been diagnosed with mental illness and other conditions
The carer provides care for a person who has an undiagnosed mental illness
Address
*
Phone
*
Email
*
Country of birth
*
Language(s) spoken
*
Identifies as CALD
*
Yes
No
Interpreter required
*
Yes
No
Identifies as Aboriginal or Torres Strait Islander
*
Neither
Aboriginal
Torres Strait Islander
Both
Relationship to care recipient
*
Is the carer a Veteran's card holder
*
Yes
No
Care recipient details
First name
*
Last name
*
Preferred name
Gender
*
Male
Female
Other
Date of birth
*
Address
(if different from carer)
Phone
Email
Country of birth
*
Language(s) spoken
Identifies as CALD
*
Yes
No
Interpreter required
*
Yes
No
Identifies as Aboriginal or Torres Strait Islander
*
Neither
Aboriginal
Torres Strait Islander
Both
Details of care recipient's mental health
*
Details of care recipients physical health
*
Please provide some details about the reason for this referral
*
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UnitingCare Wesley Bowden Inc ABN 65 440 352 199
77 Gibson Street, Bowden SA 5007
Rev. 08/21 V1