Partners in Recovery (PIR) Sunshine Coast and Gympie
For more information please call 1300 747 724
Referral Form
DETAILS OF REFERRER
Name _______________________________________ Organisation _______________________________________________
Position Title ________________________________________ Phone ______________________________________________
E-mail (required)__________________________________________________________________________________________
DETAILS OF PERSON BEING REFERRED
Name ____________________________________________ Gender ______________ DOB _____________________________
Address _________________________________________________________________________________________________
__________________________________________ Phone Number/s _______________________________________________
Does the person identify as Aboriginal and/or Torres Strait Islander _________________________________________________
Has the Partners in Recovery program been explained to the person?
YES
NO
Does the person consented to PIR sending de-identified data to the Department of Health and their information being used within
the PIR agency? (See pg.2 Your Information – It’s Private)
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? If yes, please provide name and contact details _________________________________
_______________________________________________________________________________________________________
REASON FOR REFERRAL TO PIR
RISK FACTORS
Please tick boxes related to areas of concern for the person to
demonstrate the complexity of the person’s needs:
Is the person at risk of harm to others? YES
Is the person at risk of harm to self?
YES
Accommodation
Food
Looking after the home
Self-care
Daytime activities
Physical health
Alcohol and / or Drugs
Social Isolation
Community Engagement
Child care
Basic education
Psychological distress
Information on condition and treatment
Financial
Employment and volunteering
Cultural and spiritual
NO
NO
Please provide some detail:
_______________________________________________
_______________________________________________
_______________________________________________
_______________________________________________
DATE OF REFERRAL: ___________________
Please fax the completed form above to 07 5456 8147
or e-mail to [email protected]
Page 1 of 2
Your Information - It’s Private
This form is about what happens to your information while you are accessing
Partners in Recovery (PIR) Sunshine Coast and Gympie.
Who are we?
The lead agency for Partners in Recovery (PIR) Sunshine Coast and Gympie is the Central Queensland, Wide Bay and Sunshine Coast
Primary Health network. The PIR team work to set up a broad range of services and supports to meet your individual needs.
What information do we collect about you?
PIR Sunshine Coast and Gympie keeps your name and contact details as well as other information about you that will help us to find
the supports and services you are looking for. Further details like your PIR Action Plan information and/or information about your
supports are also recorded each time you connect with your PIR team member. Information that doesn’t include identifying data is
provided to the Department of Health for mandatory reporting, monitoring and improvement purposes.
Why do we collect your information?
The information we collect helps us to keep up-to-date details about your needs and journey to mental wellbeing, so we can better
manage and plan the supports and services you seek. The information collected helps us to know if supports are working and what
needs to be done to make them work better.
Who else sees your information?
No-one else will see your information unless they are providing support to you under the PIR program. With your consent, we will
provide information to these services to help them to meet your needs. Your personal information can only be disclosed without
your consent where there is a risk of harm to yourself or others - in a medical emergency, for example. This is permitted under
Queensland law and applies to everyone equally.
What say do you have in what happens to your information?
You have the final say in what happens to your information. Information about you can only be collected and used if you sign the
PIR Sunshine Coast and Gympie consent form. If you do not sign the consent form, we will be unable to facilitate services and
supports for you. Your signed consent is required for you to participate.
How will your information be protected?
We are committed to protecting the privacy of your information. We store your information securely and hold it in the strictest
confidence, as required under Queensland law.
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 if you have any questions or feedback about what happens to your information while you
are with PIR, if you wish to access your record or change or cancel your consent. Please ask a PIR team member for a copy of the
Rights and Responsibilities and/or Feedback and Complaints form if required.
Please contact the central PIR Sunshine Coast and Gympie team on 1300 747 724 for more information.
Page 2 of 2