APPLICATION for PERSONAL HELPERS AND MENTORS …

1 phams : ApplReferr/0115 Version 11 Page 1 of 5 APPLICATION for PERSONAL HELPERS AND MENTORS PROGRAM ( phams ) ALL INFORMATION STRICTLY CONFIDENTIAL TO BE COMPLETED BY REFERRING AGENT DATE RECEIVED: _____ SECTION A APPLICANT S PERSONAL INFORMATION SURNAME: _____ FIRST NAME: _____ :_____ CURRENT ADDRESS: _____ Postcode:_____ POSTAL ADDRESS: _____ Postcode:_____ TELEPHONE: _____ MOBILE:_____ EMAIL: _____ GENDER: _____ COUNTRY OF BIRTH: _____ LANGUAGE(S) SPOKEN:_____ INTERPRETER REQUIRED YES NO If Yes which language:_____ Does the applicant identify as being: Aboriginal: Yes No Torres Strait Islander: Yes No Culturally and/or Linguistically Diverse (CALD): Yes No OOHC: Yes No Humanitarian: Yes No Homeless: Yes No SECTION B PARENT / GUARDIAN / CARER DETAILS NAME: _____ RELATIONSHIP: _____ TELEPHONE: _____ MOBILE:_____ EMAIL: _____ ADDRESS:_____ PLEASE NOTE: if the applicant is under the age of 18 years or under legal guardianship then the parent / guardian must sign the Consent for the release of this information.

2 SECTION C referral SOURCE REFERRER S NAME: _____POSITION: _____ AGENCY NAME (If relevant): _____ ADDRESS: _____ TELEPHONE: _____ MOBILE:_____ EMAIL: _____ How long has the applicant been known to you? _____ phams : ApplReferr/0115 Version 11 Page 2 of 5 SECTION D REASON FOR referral & DETAILS OF SUPPORT NEEDS As phams is Recovery focussed how could this person be supported with their own ideas of Recovery? Please suggest 2 or more areas where phams could support Recovery Goals. What are the barriers that are impacting on the applicant achieving these goals presently?

3 SECTION E ADDITIONAL INFORMATION Does the applicant have a diagnosed mental illness? Yes No What diagnosis does the applicant have? 1. 2. 3. 4. If there is no formal Mental Health diagnosis, what are the issues? Are any of the following currently providing Mental Health support and/or treatment to the applicant? (Please tick appropriate box) Mental Health Service Psychiatrist Clinical Psychologist General Practitioner Family Carer Service Providers Other Please provide details: phams : ApplReferr/0115 Version 11 Page 3 of 5 Will the applicant benefit by participating in a recovery focused program?

4 YES NO Requires assistance with community engagement and living skills development YES NO Is able to make informed decisions and capable of giving informed consent? YES NO Is willing to address non-mental illness related issues eg. Substance/alcohol use YES NO Is currently receiving residential mental health services ( ) YES NO Is currently requiring in-patient mental health services YES NO Is currently in an alcohol or other drug treatment residence YES NO Is currently in prison, remand or corrective institution YES NO Lives alone Lives with parents Lives with partner / spouse and / or children Lives alone with children Lives with other related person(s) Lives with unrelated person (s) Is there a current Domestic Violence situation?

5 Is there a current order for: Community Treatment Order: YES NO Apprehended Violence Order: YES NO Other Order: YES NO If YES to any of the above, please provide details: SECTION F SUPPORTING DOCUMENTATION Where available, please provide the following attachments and tick if attached to this referral : MHOAT: LSP HoNOS k10 RISK ASSESSMENTS RELEVANT REPORTS OTHER INFORMATION Details: _____ _____ phams : ApplReferr/0115 Version 11 Page 4 of 5 SECTION G CONSENT I, _____, (Name of Applicant) give consent to the PERSONAL HELPERS & MENTORS staff of New Horizons to liaise with and to seek information pertaining to this referral from the referral source concerning matters related to this APPLICATION , for the period of this APPLICATION process.

6 I also give consent to New Horizons to keep a record of my referral and to share my referral with other service providers, if necessary. I understand that this information will be coded to protect my identity and will only be accessible to the services that I come into contact with. I agree to allow support staff to call me (or my designated contact person if I am not contactable) in order to update my information and to see if I am still interested in support services. I confirm that I am interested in a PERSONAL Helper and Mentor assisting me with my PERSONAL goals. _____ DATE: _____ Signature of Applicant _____ DATE: _____ Signature of Referrer *Please forward completed form and any attachments to the phams Coordinator in the relevant area.

7 Ryde / Hornsby Ku-Ring-Gai 15 Twin Road North Ryde NSW 2113 T: 02 9490 0029 F : 02 9887 2823 Lower North Shore/Northern Beaches 15 Twin Road North Ryde NSW 2113 T: 02 9490 0054 F : 02 9887 2823 Redfern/Waterloo-Croydon/Bankstown Unit 4/154 Renwick Street Marrickville NSW 2204 T: 02 8755 4705 F : 02 9573 0598 Liverpool / Fairfield Lot 4 Lady Woodward Drive Miller NSW 2168 T: 02 8784 3706 F : 02 9825 9575 Central Coast 64 William Street Gosford NSW 2250 T: 02 4372 9807 F: 02 4322 7944 Macleay / Hastings P O Box 5420 2/133-137 Gordon Street Port Macquarie NSW 2444 T: 02 6588 8115 F: 02 6588 8177 Lake Macquarie 1/28-38 Smart Street Charlestown NSW 2290 T: 02 4037 0410 F: 02 4943 4944 Greater Newcastle 1/28-38 Smart Street Charlestown NSW 2290 T: 02 4037 0422F: 02 4952 1174 Lismore PO Box 5202 East Lismore NSW 2480 T: 02 6626 0010 F: 02 6622 1977 Tweed PO Box 6284 South Tweed Heads NSW 2486 T: 07 5506 4314 F.

8 07 5524 7611 * The Privacy Act requires the applicant or person responsible to sign this form giving their consent for the release of their information and * The referrer and applicant agree that no information has been withheld and that all information provided is accurate, correct and necessary for New Horizons Enterprises Limited to provide a Duty of Care to the applicant and meet its obligations to staff and volunteers. phams : ApplReferr/0115 Version 11 Page 5 of 5 PERSONAL HELPERS and MENTORS Applicant Risk Assessment Applicant name: Date: Issue: Please circle Yes (Y) or No (N) for each risk category.

9 If Yes please tick low, medium or high category box Y N Category Brief Description Plan/ Support in Place: List Support Support Required: List Requirements RECOVERY RISK ASSESSMENT Risk to engaging in Recovery Low: Limited insight into PERSONAL mental health Mod: Minimal insight into PERSONAL mental health High: No insight into PERSONAL mental health Y Low Mod High N Risks associated with Mental Health Low: History or poor medication compliance Mod : PERSONAL risk taking behaviour when unwell High: Dangerous behaviour towards self and others when unwell leading to frequent hospital care Y Low Mod High N Risk due to Accessing Services Low: Poor planning / self care skills Mod: Reliance on clinical support, disempowered High: Institutionalised, actively overuses clinical treatment options / medication to manage mental health Y Low Mod High N Risk due to Trauma/Torture Low: Minimal or none Mod: Previous history of Trauma/Abuse High: Severe history of Trauma/Torture/Abuse Y Low Mod High N Risk due to lack of Valued Role Low: Minimal social engagement with non paid staff Mod.

10 Limited social / family networks High: No work history, limited education, no routine Y Low Mod High N STAFF SAFETY RISK ASSESSMENT Risk of Violence / Aggression: Low: Irritable, verbally abusive, makes threats Mod: History of Domestic Violence, assaults other people High: Criminal conviction for assault, Probation / Parole Y Low Mod High N Risk associated with Environment Low: Lives in high density public housing Mod: Lives with violent, dangerous other people High: Lives in a highly dangerous environment due to Drugs, weapons, criminal associations etc. Y Low Mod High N Drug and Alcohol Risks Low: Loss of self-control, not seriously addicted Med: Craving or dependence on alcohol/drugs, High: Incapacitated by alcohol/drugs.