SIL REFERRAL

Help us get the word out, our way of saying…Thank You!

Supported Independent Living (SIL) Referral Form

Please complete all sections. Incomplete referrals will not be accepted. We’ll get back to you as soon as possible.

- Step 1 of 7

Referrer Details

Name *

Agency/Position *

Postal Address

Postcode *

Phone *

Email *

How did you hear about us?

Website
Social Media
Event
Friend/Family/Another Client
Radio
Google
Flyer
Advertising
Other

Please provide details

Applicant to Complete

Full Name *

First

Last

Preferred Name

Date of Birth *

Address *

Postcode *

Phone *

Email *

Gender *

Female
Male
Transgender Female (MTF)
Transgender Male (FTM)
Non-Binary
Prefer not to disclose
Different Identity

Please provide details *

Sexuality

Straight/Heterosexual
Lesbian/Gay/Homosexual
Bisexual
Unsure
Prefer not to disclose
Self describe

Please provide details

Intersex Status

Yes
No
Unsure
Prefer not to disclose

Applicant to Complete

Pronouns

She/Her/Hers
He/Him/His
They/Them/Theirs
My Name/None
Other

Please provide details

Relationship Status *

Single
Married
Separated
Divorced
Widowed
Defacto
Self describe

Please provide details *

Aboriginal *

Torres Strait Origin *

Ethnicity *

Country of Birth *

Culturally & Linguistically Diverse *

Main Language Spoken *

English
Other

Please provide details *

Interpreter Required *

Children

Source of Income *

Age Pension
Carer's Allowance
Disability Pension
Paid Work
Youth Allowance
Department of Veteran's Affairs
Unemployment (Newstart)
Other

Please provide details *

Living *

Living Independently
Living with Family Member/Carer
Other

Please provide details *

Hold a DVA Card?

If Yes, what type?

Gold
White
Other

Centrelink Number

Expiry

Medicare Number

Expiry

Private Health Cover

Provider

Member ID

Ambulance Cover

Are you currently receiving services from another program within Abilities Enabled?

Contacts

Name *

Nominated support person (Next of Kin/Alternative Contact)

Phone

Mobile *

Email *

Relationship *

Do you have a case manager?

Name *

Organisation *

Phone

Mobile *

Email *

Do you have a guardian appointed?

Name *

Phone

Mobile *

Email *

Do you have a public trustee?

Name *

Phone

Mobile *

Email *

Do you have a GP?

Name *

Phone

Mobile *

Email *

Which of the above is your preferred contact? *

Support Person
Case Manager
Guardian Appointed
Public Trustee
GP

Preferred method of contact

Text
Phone call
Email
Mail
Other

Please provide details

Health and Wellbeing

Existing NDIS Plan? *

NDIS Plan Number *

Formal mental health diagnosis? *

If Yes, please provide details *

Drug and Alcohol Use

Alcohol *

None
Current Use
In Recovery
History of use

Please provide details *

T.H.C. (Cannabis) *

None
Current Use
In Recovery
History of use

Please provide details *

Benzodiazapines *

None
Current Use
In Recovery
History of use

Please provide details *

Opioids *

None
Current Use
In Recovery
History of use

Please provide details *

Stimulants *

None
Amphetamines
Dexamphetamines A

Please provide details *

Other *

None
Hallucinogens
MDMA - Ecstasy
Prescription Drugs
Solvents

Please provide details *

Cigarettes *

None
Current Use
In Recovery
History of use

Please provide details *

Any associated risk behaviours or problems? *

(Injecting, overdoses, Hepatitis status)

While I am a resident, 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 *

Agree
Disagree

If Disagree, please provide details *

Mental and Physical Health

Do you have any physical/health issues or disabilities? (tick all that apply and provide additional information below)

Diabetes *

Podiatry *

Bruise or bleed easily *

Dental *

Heart complaints *

Ulcerations *

Liver disease *

Asthma *

Epilepsy *

Allergies *

HIV/AIDS *

Allergic to medication *

Blood pressure *

Acquired head injury *

Speech *

Thyroid problems *

Visual *

Eating disorders *

Hearing *

Substance abuse *

Mobility impairments *

Women’s health screens *

Men’s health screens *

Respiratory disease *

Intersex variation *

Transgender health screens *

Other *

If Yes, please provide details *

Please provide additional information, include the impact on your life and relating support needs *

Do you have any mobility aids? *

If Yes, please provide details *

Do you take regular medication? *

Do you require support taking your medication? *

Do you use a Webster Pack? *

Any hospital admissions in the last 12 months? *

Provide full details of any admissions (including date and reason) *

History and Support

Do you have any past or current legal issues? *

If Yes, please provide details *

Are there any particular tasks you find challenging? *

If Yes, please provide details *

What support do you need? (Tick all that apply) *

Getting in/out of bed
Bathing
Dressing/undressing
With continence
Toileting
Washing
Cooking
Medication
Eating
Emotional support
Laundry
Shopping
Gardening
Cleaning
Keeping safe
Communicating
With documentation
Transport
Budgeting
Computer/IT skills
Social/family contact
Family relationships
Accessing medical/health appointments
Engaging with social groups
Advocacy (someone to talk on your behalf)
Information of services/support
Psycho-education (e.g. stress management)
Accessing counselling/talking to someone
Others

Please specify *

Additional comments

Consent

Terms and Conditions *

I acknowledge the information provided is true and correct. I agree that Abilities Enabled may contact my health service providers to gather additional information to assist with my referral if needed. I consent to this referral being submitted for consideration of Abilities Enabled Group.

Name *

Date *

If Guardian, provide a copy of your Guardian Order issued by the State Administrative Tribunal

Guardian Name

Date