SILS Referral

Consumer Details

Name*

First Last

DOB

Gender

Gender other*

Are you

Torres Straight Origin
Aboriginal
Culturally And Linguistically Diverse (CaLD)
None of these

Phone

Email

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Primary Diagnosis/Disability

Secondary Diagnosis/Disability

Status

Children

Yes
No

Living Situation

Living Situation other*

Guardian/Primary Carer Details

Carer Name

First Last

Relationship to consumer

Carer Phone

Carer Email

Carer Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Is this an emergency contact?

Yes
No

Referrer Details

Referrer Name*

First Last

Organisation*

Position*

Referrer Phone*

Referrer Email*

Referrer Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

NDIS Details

NDIS Number

Planned Start Date

Planned End Date

Service Category being requested for Consumer: (Please fill in where relevant)

Assistance With Daily Life Tasks In A Group Or Shared Living Arrangement
Assistance with Daily Self Care (Core Supports)
Assistance to Access Community (Core Supports)
Specialist Coordination
Coordination of Supports
Increase Social and Community Participation (Capacity Building Supports)
Improved Daily Living Skills (Capacity Building Supports)
Improved Living Arrangements (Capacity Building Supports)
Psychosocial Recovery Coach

Funding Available In Plan

Hours Of Support Per Week

How Did You Hear About HCG?

How Did You Hear About HCG other*

Introduction to Consumer

General Information

Please indicate consumer’s current overall situation, general background information, history, like/dislikes, etc., (This avoids the consumer from repeating his/her story during the initial meeting with HCG)

Has the Consumer/Guardian consented to this referral?*

Yes
No

SILS Compatibility Assessment

Do you have any access or mobility requirements?

Yes
No

Access or mobility requirements details*

If yes, please provide details (Some examples include, slip/trip/fall hazard, walking frames, railings, wheelchair, stairs, hoist requirement, home modifications)

Do you require assistance with Communication?

Yes
No

Assistance with Communication details*

If yes, please provide details

Can you share accommodation with the opposite gender?

Yes
No

Sharing accommodation with the opposite gender details*

If no, please provide details as to why

Do you have any specialised Transport requirements?

Yes
No

Specialised Transport requirements details*

If yes, please provide details such as; I need a specific vehicle, I wear a harness, seat belt guard, child lock

Do you have any special dietary requirements?

Yes
No

Special dietary requirements details*

If yes, please provide details

Do you have any behaviours or specific risks to mention?

Yes
No

Behaviours or specific risks details*

Please indicate any risks/complexities identified by your organisation and attach any risk assessments or Behaviour Support Plans if available.Please also note any concerns or prior history around, absconding, verbal/physical aggression, self-harm, property damage, sexualised behaviours and criminal history.

Behaviours or specific risks files*

Drop files here or

Have you been evicted from private/government or SIL housing before?

Yes
No

Evicted from private/government or SIL housing details*

If yes, please provide details

Do you have any approved Restrictive Practices?

Yes
No

Approved Restrictive Practices details*

If yes, please provide details attach relevant supportive documentation

Approved Restrictive Practices files*

Drop files here or

Do you have any other special needs that need to be considered?

Yes
No

Any other special needs details*

If yes, please provide details such as; I have hearing impairment, vision problems etc.

Do you take any current medications?

Yes
No

Current medications details*

If yes, please provide details

Medical Professionals and Services who Support Me

(Doctors, OT’s, Phycologists, Dentists, day programs, other organisations)

Name 1

First Last

Phone 1

Email 1

Address 1

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Occupation 1

Contact 2

Name 2

First Last

Phone 2

Email 2

Address 2

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Occupation 2

Contact 3

Name 3

First Last

Phone 3

Email 3

Address 3

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Occupation 3

Contact 4

Name 4

First Last

Phone 4

Email 4

Address 4

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Occupation 4

Family and Relationships Network

Regular family contact occurring that we should encourage whilst in HCG accommodation?

Name 5

First Last

Phone 5

Email 5

Address 5

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Details 5

Contact 2

Name 6

First Last

Phone 6

Email 6

Address 6

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Details 6

CAPTCHA

Consumer Details

Guardian/Primary Carer Details

Referrer Details

NDIS Details

How Did You Hear About HCG?

Introduction to Consumer

SILS Compatibility Assessment

Medical Professionals and Services who Support Me

Contact 2

Contact 3

Contact 4

Family and Relationships Network

Contact 2

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