Referral Form
DETAILS OF REFERRER
Name: <DrName>	Organisation: <Practice>	
Position Title : <DrQualifications>	Phone : <UsrPhone>	
E-mail (required): <DrEmail>		

DETAILS OF PERSON BEING REFERRED
Name: <PtFullName>	Gender: <PtSex>	
Date of Birth: <PtDoB>	Phone Number/s: <PtPhoneH><PtPhoneMob>	
Address: <PtAddress>	<PtCity>	
Has the PIR program been explained?    	  YES        NO	
Does the person identify as Aboriginal and/or Torres Strait Islander?  (Please specify	<PtEthnicity>	
Does the person consent to the referral? Note: PIR will send de-identified data to the Department of Health; individual personal information will be shared with the NDIA (See pg.2 Your Information) 	  YES        NO (if ‘no’, do not proceed with referral)	
Primary mental health diagnosis   		
Year person was first treated for mental illness 		
Year person was last hospitalised for mental illness 		
Person’s source of income		
Does the person have a Carer? If yes, please provide name and contact details   		
Does the person have a Case Manager with Central Queensland Mental Health Alcohol Other Drugs Service? 	  YES        NO	
If yes, please provide name and contact details  		

REASON FOR REFERRAL TO PIR 
Please tick boxes related to areas of concern for the person to demonstrate the complexity of the person’s needs:	PREFERRED SERVICE PROVIDER
If eligible for support through Partners in Recovery, the person will be contacted by a Support Facilitator from the local PIR organisation:	
 Mental health/wellness
 Substance use
 Physical Health
 Intimate relationships 
 Safety to self/others
 Parenting
 Social life
 Sexual expression
 Transport
 Looking after the home	Banana Shire	 Anglicare                                    
Woorabinda	  Red Cross                                   
Emerald	  Anglicare                                    
Gladstone	  Community Solutions               

DATE OF REFERRAL: <TodaysDate>
Please e-mail completed form to pirref@ourphn.org.au 

Your Information 
This form is about what happens to your information while you are accessing Partners in Recovery (PIR) 
Who are we?
We are part of the PIR Organisation operating in your region, working together in partnership with other services and supports across different sectors to meet the full range of your needs.

What information do we collect about you?
We keep your name, contact details, and other information about you to help us meet your needs. Other details such as your action plan information and/or information about your supports are recorded each time you visit

Why do we collect and share your information?
The information we collect helps us to keep up-to-date details about your needs. We use the information we collect to better plan the supports you may require and to track our performance as a service provider.
The National Disability Insurance Scheme (NDIS) will begin in the Sunshine Coast January 2019. At a State and Commonwealth Government level, there is an agreement about the transition of support across to the NDIS for people who are currently receiving other forms of government funded support, such as Partners in Recovery. To ensure a smooth transition, the Commonwealth Government has requested that the information about Partners in Recovery participants is shared with the NDIS.
Who sees your information?
Your privacy is protected by legislation so you have a right to control who sees your information. Your information will only be shared when you consent or where disclosure is permitted under privacy law such as in the case of a medical emergency. 
De-identified information is information that does not contain your name, contact details, or any information that could identify you as an individual. We are required to provide de-identified information to the Department of Health for monitoring and improving our service. With your consent, de-identified information is also provided to the national evaluators who have been appointed by the Department to conduct an evaluation of the PIR initiative.
What say do you have in what happens to your information?
Your consent to share information is indicated by you signing the consent form. The consent form allows you to identify which services and support people you will permit PIR to have conversations with about co-ordinating your care. You can change your consent at any time without any penalty.  PIR Support Facilitators are happy to discuss your concerns and answer any questions you may have.

Can you access your information?
Yes, you have the right to access information held by us about you, unless we can show a good reason for it not to be provided. You can also request that your information be amended if you wish. Please talk to your PIR Support Facilitator.