Hearing Voices Community Group

Hearing Voices Community Group Online Referral

What is the Hearing Voices Group

TeamHEALTH’s Hearing Voices Group is for people with shared experiences who come together to support one another. The group offers a safe space where people who hear, see or sense things that other people don’t, can feel accepted, valued and understood.

PARTICIPANT DETAILS

Participant's Name:

Preferred name

DOB

Gender

Email Address

Contact Number

Address

Emergency Contact No

Country of Birth

Main Language spoken at home

Origin

Community (if applicable)

Interpreter Required?

REFERRAL DETAILS

Reason for referral

Referrer contact details

Relationship to client

Contact Number

Date of Referral

Consent

I consent to this referral/ verbal consent has been gained to complete this referral. I understand that this information will be stored on the TeamHEALTH system and that my details will be de-identified if they are used in reporting. I give permission for TeamHEALTH to discuss this information for the purposes of establishing and receiving supports.

TeamHEALTH uses personal information to assist in the coordination and provision of services. Individuals are not required by law to provide this information or consent to this proposed use and disclosure of information. The information provided to TeamHEALTH will be stored in accordance with the Australian Privacy Principles established under the Privacy Act 1998 (Commonwealth) and Northern Territory of Australia Information Act.

I Consent

In the absence of written consent, verbal consent was gained

Any dietary requirements or food allergies?

RISK ASSESSMENT

Self-harm

If yes:

Suicide (thoughts, plans attempts)

If yes:

Violence/aggression

If yes:

Abuse/trauma

If yes:

Substance Use

If yes:

Diagnosis

Current Medications

Other Identified Risks

Protective Factors

COMPLETING THIS FORM

Please call TeamHEALTH on 1300 780 081 if you need any assistance completing this form.

TeamHEALTH will contact the participant or Public Guardian within two working days of receiving this form.