Client UR Number: TextSurname: TextGiven Name: TextDate of Birth: Text

OPTIONAL MODULE: 12

CARER INVOLVEMENT

PURPOSE OF MODULE
To ascertain whether the consumer has a carer or other friend, family member or individual who is involved in their care.
WHO CAN ADMINISTER THIS MODULE?
This module is to be completed by a clinician based upon discussion with the client and information gathered during the assessment / INSTRUCTIONS
  1. Complete all areas that apply
  2. If unsure whether a question applies discuss withconsumer
  3. Discuss types of support that can be offered to the carer/family and how/ or if consumer would like carerinvolved
  4. If consumer declines direct carer involvement, discuss with consumer ways of offering indirect support to careras appropriate (i.e. resources, support groups, etc.).

CARER DETAILS#1A#

Surname:
Click here to enter text. / Given Name:
Click here to enter text. / Other Names:
Click here to enter text.
Address (Unit/Street):
Click here to enter text. / Suburb:
Click here to enter text. / Post Code:
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Gender:
Click here to enter text. / Date of Birth:
Click here to enter text. / Marital Status:
Click here to enter text.
Dependent Children:
☐ Yes ☐ No
If Yes how many?
Click here to enter text. / Carer Status:
Click here to enter text. / Living Arrangement:
Click here to enter text.
Home Phone:
Click here to enter text. / Mobile Phone:
Click here to enter text. / Preferred Method of Contact:
Click here to enter text.
Email address:Click here to enter text.
Country of Birth:
Click here to enter text. / Preferred Language:
Click here to enter text.
Interpreter Required:
☐ Yes☐ No / Aboriginal/Torres Strait Islander:
☐ Yes☐ No☐ No answer
Medicare Number:
Click here to enter text.
Healthcare Card:
☐ Yes ☐ No / Employment Status:
Click here to enter text. / DVA Card: ☐ Yes ☐ No
DVA Card Type:Click here to enter text.
DVA Card Number:Click here to enter text.

IMPACT ON CARER’S#2A#

Emotional Health (e.g. experiencing any: depression or anxiety, loss of sleep, anger, guilt or difficulty concentrating) / Click here to enter text. /
Relationships (any frequent arguments, feeling distant, giving up own hobbies to care for loved one) / Click here to enter text. /
Other family members (not having enough time for friends and family, finding drugs or alcohol in the home) / Click here to enter text. /
Financial stress (lost money due to inability to work, excess expenditures to care for loved one) / Click here to enter text. /
Physical Violence (any physical violence experienced while caring for loved one) / Click here to enter text. /
Legal Issues (any legal problems you’ve had to deal with while caring for loved one) / Click here to enter text. /
Physical Health (experienced physical problems, have had to take medication for physical ailments) / Click here to enter text. /

FOLLOW UP ACTION PLAN#3A#

SERVICE / INTERVENTION TYPE(S) REQUIRED
Consumer agreeable to carer involvement in treatmentYES ☐NO ☐
Consent given to speak with carer YES ☐NO ☐
If no, consider other ways of providing opportunities for carers to participate without breaching consumer confidentiality i.e.
  • Providing information about their consumer's mental health in general terms and offer reassurance about the supports that monitor the consumer's wellbeing.
  • Provide an opportunity for the carer to present their issues, to have them listened to and taken into account in the assessment, planning and delivery of services to the consumer
  • Provide opportunities for the carer to be involved in the organisation at the service level, even though their involvement in decision making about the consumer is limited
  • Offer support to help them access carer support and advocacy services.

Carer Support offered
☐Carer’s Rights and Responsibilities statement discussed and provided to carer
☐Family Single Sessions offered
☐Carer involvement in consumer’s Recovery Goals, care planning and discharge planning
☐Psycho Education around their loved ones conditions
☐Resources, fact sheets and relevant materials offered to carer
☐Support and referral information provided to carer (i.e. respite services, counselling,crisis support, important contact numbers, etc.)
☐Education and training offered to maximise carers wellbeing and ability to care and advocate for the consumer
☐Other:Click here to enter text.

FOR STAFF ONLY

Clinician name: TextPosition: TextSignature: TextDate: Text

Form Name: Optional Module 12Version: 1.0