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Referral Form

"*" indicates required fields

Name of Client*

Date of Birth*

Phone Number

Address of Client*

Next of Kin*

Next of Kin Phone Number

Date of Referral*

Self-Referral*

Yes

Name of Referrer*

Organisation*

Referrer Phone Number

Referrer Email

Is the client / guardian aware?

Yes

Has consent been given for this referral?

Yes

Reason for Referral (please provide a brief summary of presenting issues / concerns*

Risk are there any immediate safety concerns? If yes, please provide a brief summary)*

Legal (are there any pending court cases?)*

Other Services (are there any other services currently working with you?)*

The reporting of domestic and family violence is everyone’s business. Should you feel your client and family are at immediate risk OR your concerned for your clients Wellbeing, please report concerns

Ambulance – 000

Police – 000/131444

MHATT 24hour Northern Territory Mental Health Hotline 1800662288

If you feel that your client would benefit from seeking urgent assistance to address significant but not imminent risk to self or others, please encourage/assist client to attend Wurli Health Service for review by GP
Wurli Community Services can offer support and advice during moments of crisis and strongly encourage clients, family, and organisation to contact the service with their concerns for advice.

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