Referral Form – Carer Support Program

Transcript

Referral Form – Carer Support Program TEAMhealth Carer Support Program Provides: Flexible support options for carers of people with mental illness whose health and wellbeing or other impediments are impacting on their ability to provide care. Services focus on:  Providing a range of education and support to assist carers to continue providing care, and/or improve their health and wellbeing through social and economic participation in the community.  Provide information about other appropriate services and support to access services, to assist carers to continue providing care.  Reduction of stigma and discrimination to ensure that, carers are better able to sustain their caring roles. Name: Address: Carer details: DOB: Gender:  Male  Female  Other Telephone: Mobile: Email address: Are you: Aboriginal:  Yes Torres Strait Origin:  Yes Country of Birth:  No CALD:  Yes  No  No Non Indigenous:  Yes  No Main Language spoken at home: Interpreter Required:  English  Other  Yes  No (list):_________________ (list):_________________ Do you feel that the care you provide is impacting on your own physical or mental health?  No  Yes  Sometimes If so what do you feel is impacting on your physical or mental health? What do you feel would support you to help maintain or improve your own health and wellbeing? Do you require urgent assistance or support, including being at risk of homelessness?  No If so what supports do you require? Are you a young carer?  No  Yes Are you a self-carer?  No  Yes This Form is uncontrolled once printed. Refer to TEAMhealth T Drive for current version.  Yes Are you an older parent carer?  No  Yes Page 1 of 3 TEAMhealth Referral Form Carer Support 118 - OPR Are you currently working?   Full time employment  Unemployed  Part time employment  Other (please explain) Do you receive a Centrelink benefit?  No If so what benefit do you receive?  Casual employment  Yes Do you receive support/assistance from family or friends?  No If so, what does this involve?  Yes  Sometimes Are you receiving support/assistance from other services?  No If so, what services are you involved with?  Yes  Sometimes Have you previously received support/assistance from other services?  No If so, what services where they?  Yes Care Recipient Details Do you care for a person with a diagnosed mental illness?  No If so what is the diagnosis of the person you care for:  Yes In a typical week, what do you do to support the person you care for?  Transport  Emotional support  Medication administration  Housework  Financial management  Assist to attend appointments  Meal preparation  Shopping  Other: ______________________________ In a typical week, how much time to you spend caring?  Less than 20 hr/week  20 - 40 hrs/week  40+ hrs/week Does the person you care for receive support/assistance from other services?  No If yes, what services are they involved with and what does this support look like?  Yes Does the person you care for have Guardianship/Trustee or Community Management Orders in place?  No  Yes If yes, what does this look like? Do you get paid a wage or salary to provide care for the person with a mental illness?  No This Form is uncontrolled once printed. Refer to TEAMhealth T Drive for current version.  Yes Page 2 of 3 TEAMhealth Referral Form Carer Support 118 - OPR Person referring or referral agent details  I confirm that as a carer I have consented for this referral to occur.  I confirm that as a carer I have consented to the sharing of information between TEAMhealth and the referring agency for referral purposes. (please note that a referral cannot be accepted without a carers consent) Carer name: Signature/s: Date: Person referring (if other than carer): Signature: Date: Organisation: Telephone: Email address: Please include any additional information and attach separate document/s as required This Form is uncontrolled once printed. Refer to TEAMhealth T Drive for current version. Page 3 of 3