Indigenous Community Support Referral Form CC-012-05

Indigenous Community Support Referral

All Referrals are Confidential

Gateway Health acknowledges the Traditional Custodians of this land on which we stand and pay our respect to the Elders, past, present and future, for they hold the memories, the traditions and the culture of all Aboriginal and Torres Strait Islander peoples.
We recognise that Aboriginal and Torres Strait Islander peoples hold a unique place as the First Peoples of this land. We are committed to providing safe, respectful and culturally inclusive services for Aboriginal and Torres Strait Islander clients, families, and communities.

Supporting access to services and community connections
Our aim is to make it easier for Aboriginal and Torres Strait Islander community members to access government and other support services that are available to the general community.
This service provides practical support, advocacy and connections to help people access the services they need in a way that feels welcoming, respectful and community focused.

How we can support
- Transport assistance
- Advocacy and practical support
- Referrals to other services
- Links to health, legal and housing services
- Support with other issues that may affect wellbeing and connection to community services

Community-informed support
Gateway Health employs an identified Aboriginal staff member in this program. We also employ staff from local Aboriginal communities across other programs, bringing an understanding of the issues, strengths and concerns their community might have.
This helps us provide support that is culturally respectful, community connected and responsive to individual and family needs.

What is your relationship to the client being referred? *

Please specify

Referrer Details

First Name *

Last Name *

Contact No. *

Email Address *

Organisation Name & Address

Does the referred client give consent for this referral to be sent to Gateway Health? *

YesNo

If the referred client is under the age of 15, does the Parent/Guardian consent for this referral to be sent to Gateway Health? *

YesN/A

Parent/Guardian First Name

Parent/Guardian Last Name

Parent/Guardian Contact No.

Referral Details

Reason for Referral - Please give as much detail as possible *

Connections to Family, Kin, Elders or Community

Would the client like us to involve or keep connected with a family member, Elder, or community Support Person as part of their care?

YesNo

Who would the client like us to keep connected with?

Would you like us to involve or keep connected with a family member, Elder, or community support person as part of your care?

YesNo

Who would you like us to keep connected with?

Please provide further details

Are there any Risk or Safety Concerns?

Is there anything we need to know to keep you and your family safe?

Are there any Court Orders pertaining to the Family/Household? *

YesNoN/A

e.g. Child Protection, Family Court Order

Please provide a brief details of court order and case worker contact information

Are there any custody arrangements for the Family/Household that may impact upon participation in this service? *

YesNoN/A

Please provide a brief description

Where did you hear about this service?

Client Registration Details

Please complete as many details as known, the fields marked with a * are mandatory.

First Name *

Last Name *

Preferred Name

Preferred Pronouns

Date of Birth *

Gender (Sex assigned at Birth) *

Contact No. *

Email Address *

Home Address *

Street address *

City *

State *

Postcode *

Please provide details of preferred safe contact method

First Nations Status

Name of Mob

Does the client identify as LGBTQIA+?

YesNoPrefer not to say

How should we record the clients Gender Identity?

Do you identify as LGBTQIA+?

YesNoPrefer not to say

How would you like us to record your Gender Identity?

Are there any needs/preferences that would assist with accessing the service?

Household Details

Living Arrangements

Please specify

Accommodation Setting

Please specify

How many children are in the household?

Please provide child's/children's age and gender

Emergency Contact Details

Full Name *

Contact Number *

Relationship to Client *

Relationship to You *

Its Yarn Time

Thank you for registering your interest in this service, our Indigenous Community Support Worker will call you to discuss the next steps regarding this referral.

Please indicate a preferred day and time for a brief phone call

Referrer's Signature *

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Referral Date *

Your Signature *

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Referral Date *

For further assistance with this referral please contact Tracey our Indigenous Community Support Worker on 0481 036 720.

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