ACCESS TO COMMUNITY REFERRAL FORM

Access to Community aims to link socially isolated people with community activities. It’s HACC PYP funded (not NDIS) to work with people under 65 who would like some support to build connections. This service is also available to carers.

Available in the cities of Yarra, Boroondara and Manningham.

Once this form is completed the coordinator (Liz) will call you. Liz can answer your questions if you are unsure if this is for you.

Who are you completing this form for? *

Client self referral form

Are you under 65 years? *

YesNo

This program is available to people under 65 who are not on NDIS.

Please reach out to your local library, neighbourhood house or community house for more options if this service is not for you.

To contact a Service Connector for assistance with aged care service connection, call 9430 9100 or email service.connection@healthability.org.au or visit the website www.healthability.org.au

Or you can call Camcare on 9831 1900.

Do you have an NDIS package? *

YesNoUnsure

This program is available to people under 65 who are not on NDIS. It is designed for carers and people requiring assistance to access community activities.

Please reach out to your NDIS service provider or go to https://www.ndis.gov.au/contact

or you can call the NDIS on 1800 800 110

PERSONAL DETAILS

First Name *

Last Name *

DOB *

Preferred gender pronoun

Are you of Aboriginal and/or Torres Straight Islander background? *

What is your preferred language? *

Do you require an interpreter? *

YesNo

CONTACT DETAILS

Address

Postcode *

Phone Number *

Preferred method of contact *

Email Address *

How did you hear about the A2C program? *

ABOUT YOU

Is there anything else you would like us to know about you before we reach out? *

CONSENT

I confirm that the above information is true, complete and accurate *

I have read the Access HC 'Rights and Responsibilities'. *

I have read the Access HC 'Privacy Policy'. *

I understand that my information may be shared with other staff at AccessHC including the Volunteer Community Connector or other health professionals *

I consent to A2C contacting my referring health service provider *

YesNo

Signature *

Draw signature|Type signatureClear

Date: *

Referral form

Has the person you are referring consented to you completing this form and sharing this information? *

YesNoRequest phone call

In order to work with this person it would be helpful if you spoke with them about the program first and get their permission to share their information.

If you need assistance or guidance in doing this, please continue to complete this form with limited information, that respects their privacy, and we will reach out to you for a discussion of a more general nature.

If you would prefer to discuss a referral first or if you have a general enquiry, you can also contact us directly on P: 9831 1913 or E: a2cprogram@accesshc.org.au

Name of referrer *

What is your relationship to the person you are referring? *

FriendFamilyProfessional service provider

Which service do you work for? *

What is your position/role title? *

What are your contact details? *

Is the client under 65 years of age? *

YesNo

This program is available to people under 65 who are not on NDIS.

Please reach out to your local library, neighbourhood house or community house for more options if this service is not for you.

To contact a Service Connector for assistance with aged care service connection, call 9430 9100 or email service.connection@healthability.org.au or visit the website www.healthability.org.au

Or you can call Camcare on 9831 1900.

Does the client have an NDIS package? *

YesNoUnsure

This program is available to people under 65 who are not on NDIS. It is designed for carers and people requiring assistance to access community activities.

Please reach out to your NDIS service provider or go to https://www.ndis.gov.au/contact

or you can call the NDIS on 1800 800 110

CLIENT PERSONAL DETAILS

What is the first name of the person you are referring? *

Client last name *

Client's Address *

Post code *

Phone number/s *

Email: *

Date of birth *

Country of Birth *

Languages spoken *

Does the client require an interpreter? *

YesNo

Health Care Card holder? (does not impact eligibility, service is free for all) *

YesNoUnsure

Emergency Contact name: *

Emergency Contact number *

Emergency contact relationship *

Reason for referral *

Observed or perceived lonelinessSelf disclosed lonelinessObserved social isolationOther

Are you aware of any risks associated with supporting this person? (such as mobility or communication difficulties) *

Is there anything else we should know that could help to successfully engage with this person and support them to be more involved in interacting with their community? *

Would you like to be informed of the outcome of this referral? *

YesNo