Date of Referral: Click or tap to enter a date.

Name of person being referred / self-referring:
Address:
Post Code:	Mobile No:	Landline No:
Email:
Date of Birth:	Click or tap to enter a date.	Gender: male ☐ female ☐ other ☐
Identifies as:	☐	An Indigenous Person	☐	A Torres Strait Islander
And / or:	☐	Interpretation Services required	☐	CaLD Please specify below:
Does this person have a current NDIS funding package:	Yes ☐ No ☐
If No – is an application for a NDIS application in process:	Yes ☐ No ☐

Referrer details:

Agency Name:
Contact Name:
Address:
Mobile:	Phone – other:
Email:
Other key workers and/or other agencies: (if relevant)

If this is a Youth Referral – Please complete the NOK details:

Name of Next of Kin / Legal Guardian	Relationship:
Mobile No:	Landline No:
Email:
Address:

Medical details:

Mental Health Diagnosis:
Other Medical Conditions: (if relevant)

GP Details:

Surgery:	GP Name:
Phone:	Fax:
Email:

Current medication:

Name of Medication:	Dosage:	Frequency:

Please indicate Support Program required:

☐	Room 226 – Youth and family support	☐	Carers
☐	NDIS support	☐	Personalised Support – Other
☐	NPAH – National Homelessness Agreement	☐	SC – Recovery Coaching
☐	D2D Living – Psycho-social centre based	☐	SC – Support Coordination
☐	CSPS – Commonwealth Psychosocial Support	☐	Indigenous Family Support
☐	Unknown

Please provide relevant social and historical information that will assist Lamp to provide individualised planning and support - eg. Family, substance abuse, self-harm, suicidal ideation:
Please provide any risk profiles, risk assessment or safety concerns regarding this referral. Please note - It is the responsibility of the referrer to disclose any at risk situation including forensic, Covid19, DV or other.
Recommended Support ratio: One worker ☐ or ☐ Two Workers

Risk Assessment attached: (Eg: R.A.M.P. or C.R.A.F. - if relevant) Yes ☐ No ☐