REFERRAL FORM_______________________________________________________________
Banyan House is a medium to long term residential drug and alcohol rehabilitation facility that uses
the Therapeutic Community model of treatment. Therapeutic Communities (TC) are drug free
residential settings that use a hierarchical model with treatment stages that reflect increased levels
of personal and social responsibility. Peer influence, mediated through a variety of group processes,
is used to help individuals learn and assimilate social norms and develop more effective social skills.
Referrals
We accept self referrals and referrals from other agencies, for example GP’s, Allied Health
Professionals, community-based agencies and other similar organisation’s can all refer a client to
Banyan House using this Referral Form. General Practitioners should include a mental health care
plan (if applicable) for the client and attach this to the Banyan House referral form. Each referral is
triaged and if sufficient information was provided to facilitate an allocation, a clinical assessment will
be offered to the client, and an appointment agreed upon to complete the assessment. Please
complete this form with as much detail as possible – inadequate information to facilitate a triage of
this referral will result in the referral being rejected.
IMPORTANT NOTICE: Once an appointment has been made with the referred client to
attend a clinical assessment, the client will be charged $85.00 for non-attendance without a
24 hour prior notice of cancellation / request to postpone appointment.
Referrer’s Details
Referring Agency:
Contact Number:
Signature:
Contact
Person:
Mobile:
Date:
Client Details
Name:
D.O.B.
Ag
e:
Known Address:
Contact Number:
Gender:
Dependents:
Ethnicity:
GP:
Mobile:
Relationship Status:
Language:
Phone:
Fax:
Legal Concerns (if any): Please note an automatic exclusion criteria applies for any
crimes against children, sexual offending, murder/manslaughter, arson and any serious
crimes of violence.
doc_280_referral form_v5
REFERRAL FORM__________________________________________________
Client’s current drug use
(Please put an * next to the person’s drug of choice)
Substance(s)
Name of
substance
Frequency
(Daily/Weekly/monthly)
Average
amount
taken per
day
Route
(Ingest/inhale/IV)
Date
last
used
Alcohol
Amphetamines
Benzodiazepines
Cannabis
Methamphetamines
(ICE)
Opiates
MDMA (Ecstasy)
LSD
Nicotine
Other
Previous AOD History/Treatment
Current Medical/Mental Health problem(s) and prescribed medication(s)
Additional Relevant Information
Please attach any further information/details that may be relevant to this
referral and
Fax to: (08) 89471093
Or
Email: [email protected]
doc_280_referral form_v5
REFERRAL FORM __________________________________________________________
Banyan House and its governing body The Forster Foundation for Drug Rehabilitation Incorporated
are dedicated to providing a best practice, evidence based specialist service.
To provide you with the best possible care we may need to share your information for clinical and
safety reasons. Times to share information may include clinical case management discussions;
provision of anonymous data for statistical analysis; using your file in file audits; for the purpose of
ensuring record keeping quality assurance; and for follow up after care programs.
Banyan House staff are aware of the importance of the need to safe guard your personal
information. We collect and handle personal information in accordance with the Information Act
and its Information Privacy Principles.
When you fill out this form it will allow us to share relevant information with people or
organisation(s) indicated below for a period of 12 months from the date this form is signed.
I,
hereby authorise Banyan House staff to obtain information from or release information concerning
my care to all clinical services/individual/organisations listed below when necessary to ensure my
safety and quality of care for the duration of my treatment at Banyan House.
NT Department of Health – (TADS, RDH, Clinic 34, TEMHS, etc)
NT Department of Justice – (Community Corrections, Court Clinicians, etc)
NT Office of Children and Families
North Australian Aboriginal Justice Agency (NAAJA)
Northern Territory Legal Aid Commission (NTLAC)
Centrelink
Psychologists J. Lamech/K. Payne/CDU Clinical Psych Student Placements
Client Signature:
Date:
Staff signature:
Date:
Staff name:
doc_280_referral form_v5
Position: