Referral Screening Tool
CS 506 F5 /
Family name * / Address*
Given names*
DOB * / Current Housing / Rooming House / Private Rental
Age / SRS / Public housing
Gender* / With friends / Family Home
Phone number / Other / Caravan
Country of Birth* / Year of arrival / Homeless
Indigenous status / Language spoken / Interpreter / Y / N
Cultural requirements: / Level of English / Spoken / N/A / Nil / Limited / Fluent
Written / N/A / Nil / Limited / Fluent
Ermha 360 only Funding type:
ISP / MACNI / FFYA / TAC / TCP
NDIS Use Only: NDIS#
Support category / # of hours / Support category / # of hours
Support Connections / Y / N / Specialist Assessment / Y / N
Support Co-ordination / Y / N / Behaviour Support Planning / Y / N
Direct support / Y / N / Behaviour Intervention support / Y / N
High Intensity / Y / N / Other / Y / N
Support person / Emergency contact / Y / N / Support Person / Emergency contact / Y / N
Name/address/contact number / Name/address/contact number
Relationship / Friend / Carer / Family / Relationship / Friend / Carer / Family
Medicare No. / Public Housing application submitted / Y / N / Housing No.
(if known)
Centrelink No. / Care Coordinator:
Agency: / Name:
Tel:
Mental Health Case Manager:
Agency: / Name:
Tel: / Case Manager:
Agency: / Name:
Tel:
Disability / Health / Mental health
No Disability / No Health issues / No Mental Health issues
ABI / Alcohol / Anti-social personality disorder
Autism / Allergy to bites or stings / Anxiety disorder
Deaf-Blind (Dual sensory) / Allergy to food / Bi-polar disorder
Hearing (sensory) / Allergy to medication / Borderline personality disorder
Intellectual / Asthma / Depression
Neurological / Cancer / Drug induced psychosis
Physical / Diabetes / Eating disorder
Psychiatric / Drugs / Personality disorder
Specific attention deficit disorder / Emphysema / Post traumatic disorder
Speech (sensory) / Heart disease / Schizo affective disorder
Vision / HIV+ / AIDS / Schizophrenia
Kidney disease
Liver disease (Hep C, cirrhosis)
Positive to TB
Other (Please specify) / Other (Please specify) / Other (Please specify)
Support Needs* / *Please provide details. Legend at the bottom of the next page
Housing / U / L / M / H
Income/Finances / U / L / M / H
Social inclusion/ networks / U / L / M / H
Legal / U / L / M / H
Physical / U / L / M / H
Emotional health / U / L / M / H
Meaningful use of time / U / L / M / H
AOD / U / L / M / H
Medication (please list) / U / L / M / H

Support services*

Service agency- past and present / Key contact: / Contact details / Type of support
Tel:
Tel:
Tel:
Tel:
Referral source/ agency* / Name
Contact details / Tel:
Referral completed by: / Date: / /
Verbal consent to share information provided* / Y/N / Date: / /
Risk Alert / Support needs
(Please summarise any risk alerts that would need to be considered. Please attach any relevant reports or plans) / U / Unknown/ has not been assessed
L / Low support required/independent/support not needed/yet to be identified.
M / Moderate support/verbal support/ limitations to skills or knowledge.
H / High Support/ Crisis management/ high risk taking/ lack of insight/complex needs yet to be addressed

VERSION CONTROL

VERSION NO. / DATE APPROVED: / SHORT DESCRIPTION OF AMENDMENT / DATE TO BE REVIEWED:
1. / 20/09/2016 / New Document / 20/09/2019
Doc No: CS 506 F5 / Version No: 1 / Date of Issue:20/09/2016
Author Title: QSO / Authoriser Title: MQS / Approver Title: CEO
CONTROLLED COPY / Uncontrolled Copy When Printed
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