New Referral Form Please enable JavaScript in your browser to complete this form. - Step 1 of 7Referrer DetailsName *Agency / Position *Address *Address Line 1Address Line 2CityState / Province / RegionPostal CodeCountryAfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBolivia (Plurinational State of)Bonaire, Saint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongoCongo (Democratic Republic of the)Cook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Kingdom of)EthiopiaFalkland Islands (Malvinas)Faroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHondurasHong KongHungaryIcelandIndiaIndonesiaIran (Islamic Republic of)IraqIreland (Republic of)Isle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea (Democratic People's Republic of)Korea (Republic of)KosovoKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesia (Federated States of)Moldova (Republic of)MonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth Macedonia (Republic of)Northern Mariana IslandsNorwayOmanPakistanPalauPalestine (State of)PanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint Martin (French part)Saint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint Maarten (Dutch part)SlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyrian Arab RepublicTaiwan, Republic of ChinaTajikistanTanzania (United Republic of)ThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUgandaUkraineUnited Arab EmiratesUnited Kingdom of Great Britain and Northern IrelandUnited States Minor Outlying IslandsUnited States of AmericaUruguayUzbekistanVanuatuVatican City StateVenezuela (Bolivarian Republic of)VietnamVirgin Islands (British)Virgin Islands (U.S.)Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland IslandsCountryPhone *Mobile *Email *How did you hear about us? *Please SelectWebsiteSocial MediaEventFamily/Friend/Another ClientRadioGoogleFlyerAdvertisingOtherOtherNextApplicant to CompleteName *FirstLastDate of Birth *Preferred NameApplicant Address *Address Line 1Address Line 2CityState / Province / RegionPostal CodeCountryAfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBolivia (Plurinational State of)Bonaire, Saint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongoCongo (Democratic Republic of the)Cook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Kingdom of)EthiopiaFalkland Islands (Malvinas)Faroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHondurasHong KongHungaryIcelandIndiaIndonesiaIran (Islamic Republic of)IraqIreland (Republic of)Isle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea (Democratic People's Republic of)Korea (Republic of)KosovoKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesia (Federated States of)Moldova (Republic of)MonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth Macedonia (Republic of)Northern Mariana IslandsNorwayOmanPakistanPalauPalestine (State of)PanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint Martin (French part)Saint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint Maarten (Dutch part)SlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyrian Arab RepublicTaiwan, Republic of ChinaTajikistanTanzania (United Republic of)ThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUgandaUkraineUnited Arab EmiratesUnited Kingdom of Great Britain and Northern IrelandUnited States Minor Outlying IslandsUnited States of AmericaUruguayUzbekistanVanuatuVatican City StateVenezuela (Bolivarian Republic of)VietnamVirgin Islands (British)Virgin Islands (U.S.)Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland IslandsCountryPhone *Mobile *Email *GenderPlease SelectFemaleTransgender Female (MTF)MaleTransgender Male (FTM)Non-binarySelf-describePrefer not to discloseDifferent Identity (Please describe)If Different Identity (please describe)Intersex StatusPlease SelectYesNoUnsurePrefer not to disclosePronounsPlease SelectThey/Them/TheirsShe/Her/HersHe/Him/HisNone/My NameOtherOther PronounsAboriginalPlease SelectNoYesTorres Strait IslanderPlease SelectNoYesEthnicityCulturally and Linguistically DiversePlease SelectNoYesCountry of BirthMain Language SpokenPlease SelectEnglishOtherOther Language SpokenInterpreter RequiredPlease SelectNoYesOccupationSource of IncomeAge PensionCarer AllowanceDisability PensionDepartment of Veteran's AffairsFamily AssistanceUnemployment (Newstart)Youth AllowancePaid WorkOtherOther Source of IncomeLiving SituationPlease SelectLiving IndependentlyLiving with family member/carerOtherCentrelink NumberCentrelink ExpiryMedicare NumberMedicare ExpiryMedicare Member IDAmbulance CoverPlease SelectNoYesAre you currently receiving services from another program within Infinity Coordination & Supports?Please SelectNoYesNextContactsNominated support person (Next of kin / Alternative contact)NamePhoneMobileRelationshipEmailDo you have a Support Coordinator?Please SelectNoYesNameOrganisationPhoneMobileEmailDo you have a Guardian Appointed?Please SelectNoYesNamePhoneMobileEmailDo you have a Public Trustee?Please SelectNoYesNamePhoneMobileEmailDo you have a GP?Please SelectNoYesName PhoneMobile Email Which of the above is your preferred contact?Please SelectSupport PersonCase ManagerPublic Trustee Guardian Appointed Preferred method of contact? Please SelectTextPhone CallEmailMailNextNDIS DetailsExisting NDIS PlanPlease SelectNoYes NDIS Plan Number (Please attach) Formal mental health diagnosis? Please SelectNoYesThird ChoiceIf yes, please provide details* Please note to be eligible for Infinity Coordination & Supports Residential Accommodation services the applicant must have ongoing clinical support guaranteed by a public mental health service, a private Psychologist or General Practitioner; or be willing to engage with one of the above mentioned services.NDIS Plan Start DateNDIS Plan End DateBilling DetailsPlease Select.Plan ManagedNDIS ManagedSelf ManagedBilling Manager NameBilling Manager PhoneBilling Manager MobileBilling Manager EmailDo you have funding available for your SIL/STA?Please Select.NoYesNextHealth & WellbeingProvide details where appropriate:Drug TypeHistory of useCurrent useAlcoholAlcohol Current UseAlcohol HistoryT.H.C. (Cannabis)THC Cannabis CurrentTHC Cannabis HistoryBenzodiazapinesBenzodiazapines CurrentBenzodiazapines HistoryOpioidsOpioids CurrentOpioids HistoryStimulantsStimulants CurrentStimulants HistoryCigarettesCigarettes CurrentCigarettes HistoryOtherOther CurrentOther HistoryAny associated risk behaviours or problems (Injecting, overdoses, Hepatitis status) While I am a resident of Infinity Coordination & Supports' Accommodation, if I am considered to be using drugs and alcohol which is impacting on my recovery, I agree to work with an appropriate Drug and Alcohol Service *I AgreeNextMedical ConditionsDo you have any physical/health issues or disabilities (tick all that apply and provide details below):CheckboxesDiabetesPodiatryBruise or bleed easilyDentalHeart ComplaintsUlcerationsLiver diseaseAsthmaEpilepsyAllergiesHIV/AIDSAllergic to medicationBlood pressureAcquired head injurySpeechThyroid problemsVisualEating disordersHearingSubstance abuseMobility impairmentsWomen’s health screensRespiratory diseaseMen’s health screensIntersex variationTransgender health screensOtherIf Other is ticked, please provide details. Include the impact on your life and relating support needs. Do you have any mobility aids? Please SelectNoYesIf Yes is selected, please provide details of equipment.MedicationHow do you feel about taking medication? Do you take regular medication? (attach your medication regime) Please SelectNoYesDo you use a Webster pack?Please SelectNoYesDo you require support taking your medication? Please SelectNoYesAny hospital admissions in the last 12 months?Provide full details of any admissions (including date and reason): HistoryForensic HistoryDo you have any legal issues we need to know about? (E.g. outstanding charges, convictions or a community treatment order)Please SelectNoYesIf yes, please provide details:Support NeedsHow many days a week do you require support?Are there any particular tasks you find challenging? What support do you need? (Tick all that apply)Getting in/out of bedWith continenceBathingDressing/UndressingToiletingWashingCookingMedicationEatingAccessing counselling / talking to someoneLaundryShoppingGardeningCleaningKeeping safeTo communicateWith documentationTransportBudgetingAccessing medical / health appointmentsEmotional supportEngaging with social groupsAdvocacy (someone to talk on your behalf)Information of services/supportSocial/Family contactPsycho-education (e.g. stress management)Computer/IT skillsFamily RelationshipsOtherOther (please enter)NextSupporting Documents ChecklistPlease refer to the following checklist to ensure your referral is complete and all relevant information is attached. Your referral must include:Primary Diagnosis of Mental Health disorderCurrent Client Management PlanBrief Risk Assessment completed by a clinicianCurrent Mental Health Treatment/Care PlanRecent Discharge SummariesOccupational Therapy (OT) Assessment (if applicable)Details of Forensic History (if relevant)Any current Community Treatment Order (CTO)Medication regimeNDIS plan (if applicable)Physical Health Assessment completed by a GP or attending DoctorConsentName of consenting applicant *Date *Name of guardian *Date *Send Referral Request