Access to Community Referral Form

The Access to Community A2C program links socially isolated people with community activities.

The program is available to work with people who would like to build social connections in their community. A2C is free and funded under both HACC PYP (not NDIS) and CHSP SSI and is delivered in the cities of Yarra, Boroondara and Manningham.

What happens once you complete this form?

Once this form is completed Liz (the Access to Community program coordinator) will call you to answer your questions and check if this program is for you.

Questions?

Visit the Access to Community webpage to learn more about the program. You can also email A2Cprogram@accesshc.org.au or call 9831 1913.

If you need help filling out this form, please type your email or phone number in the box below and we will contact you. If you need an interpreter, please tell us the language you speak.

Who are you completing this form for? *

Client self referral form

PERSONAL DETAILS

First name *

Last name *

DOB *

Pronouns

What is your preferred language? *

Is an interpreter required? *

YesNo

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

CONTACT DETAILS

Address *

Phone number *

Preferred method of contact

Email address *

Do you have an NDIS package? *

YesNoUnsure

Please tell us how you heard about this program. This helps us improve our service. *

ABOUT YOU

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

CONSENT

By submitting this form, you agree to the following:

I have read the AccessHC 'Rights and Responsibilities'.

The information I have provided is true, complete and accurate.

I have read the AccessHC '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

Referral form

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

YesNoRequest a phone call

If you can, please speak to the person and get their permission for their information to be shared. This will be very helpful for us.

If you need help doing this, please complete this form with limited information, that respects their privacy, and we will reach out to you for a general discussion.

If you would like to talk about a referral first or have questions, please call 9831 1913 or email 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? *

CLIENT PERSONAL DETAILS

Client's first name *

Client last name

Client's address *

Phone number/s *

Email: *

Date of birth

Country of birth

Languages spoken

Does the client require an interpreter?

YesNo

Is the person a Health Care Card holder? (this does not impact eligibility, service is free for all) *

YesNoUnsure

Emergency Contact name: *

Emergency Contact phone 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