QUIHN THERAPEUTIC SERVICES - REFERRAL FORM

COUNSELLING & GROUP WORK

Date Referral Made: _____/_____/_____

Client Details

Given Name: / Family Name:
Street address: / Postcode:
Postal address: / Postcode:
Contact Phone number(s):
Gender:  Male  Female  Intersex/Indeterminate / Date of Birth: ____ / ____ / _____
Referred for:  Individual Counselling  Group Work  Case Management

Referrer Details

Worker Name: / Position Title:
Email: / Agency Name:
Phone Number: / Fax:
Address:

Relevant Referral Information

Substances used (past or current):
Current Psychiatric Diagnoses:
Is the client aware of the referral to QuIHN?
Does the client agree to the referral to QuIHN?
Have you or any other workers in your organisation ever felt threatened or intimidated by the client?
Does the client have a history of violence or abuse to others?
Is there any other information that you feel would be useful for us to know?
How do you think the client would benefit from engaging with QuIHN?
Are there any barriers to engagement for the client?
Clients current involvement with other services (please list services):
Significant others supporting the client:

If the client would like us to discuss their case with another organisation or person please ask them to complete the attached Authorisation to Gain or Release Information form

Thank you for your referral to QuIHN. Please call us if you require further information.

AUTHORISATION TO GAIN OR RELEASE INFORMATION

QuIHN can support you better if we are able to work with other agencies that you are accessing support from. By signing this form, you are giving your permission for QuIHN to contact the agency / individual specified below to gain and/or release information about your situation.

I, ______(D.O.B: _____/_____/_____)

hereby authorise the QuIHN ______

Program to gain and/or release information about my case with;

Agency______

Phone Number: ______Fax Number: ______

or (please complete only one option)

Individual ______of ______(program/service)

Phone Number: ______Fax Number: ______

I understand the information gained / released may include (please tick):

My appointment attendance at QuIHN or the organisation / individual listed above

My clinical diagnosis

My treatment history, current treatment or support plan and progress against my treatment or support plan with the QuIHN program listed above

My current treatment or support plan (for the QuIHN program listed above) and progress with the organisation / individual listed above

Any future changes in my condition

Any future changes to my treatment or support plan

Other: ______

Other: ______

I understand that QuIHN will have ongoing discussions about my treatment with the agency / individual specified above, for the term of my registration as a client of QuIHN.

I understand that information about my case is confidential and protected by state and federal law. I understand that QuIHN operates on the basis of limited confidentiality.

I can cancel this Authorisation to Gain and/or Release of Information at any time, but I understand that the cancellation will not affect any information that was already released before the cancellation.

Client

Print and Sign ______Date ___ /___ /___

Worker – as witness

Print and Sign ______Date ___ /___ /___

TherapeuticReferral Form V1
Please refer to Qudos for most recent version / Page 1 of 2