Partners In Recovery (PIR) North Coast NSW
Application Form
Phone: 1800 022 066
Fax: (02) 6658 7963
Email: [email protected]
Date: ____ /____ /__________
1. Eligibility Criteria for participation in PIR
PIR has some eligibility criteria that must be met.
Please consider carefully every item below before proceeding with this application.
1.1
Are you experiencing severe and persistent mental illness?
1.2
Do you have unmet needs that require lots of services from multiple providers?
1.3
Do you find it hard to engage with the various services you need and feel you need more support to access
services?
1.4
Do you currently have no case coordination to assist with accessing services and supports or do you find
the coordination you have is not adequate or may be contributing to your problems in getting help?
PLEASE NOTE: PIR IS NOT DESIGNED TO HELP WITH EMERGENCY OR CRISIS SITUATIONS
2. Applicant Details
Please share some basic details with us so we can consider your application and contact you about it.
First Name: ___________________________________Last Name: ________________________________________
Preferred name/s:______________________________
Date of Birth: _____ /_____ /_______
Gender:
M
Is this date an estimate?
F
Yes
Other
No
Street Address:__________________________________Suburb:__________________________
P/code:_______
What is the best way to contact you, eg. phone/email? (add details)_______________________________________
_______________________________________________________________________________________________
Do you identify as:
Aboriginal
Torres Strait Islander (TSI)
Neither
Both
What language do you speak? ______________________If not English, do you need an interpreter:
Unsure
Yes
No
What is the primary mental illness you are experiencing? ________________________________________________
How long have you been experiencing this? ___________________________________________________________
Has PIR helped you before?
Yes
No If yes, where? ______________________________________________
3. Reason/s for applying to PIR
Check as many boxes as required.
Mental Health
Physical Health
Employment
Other ____________________________________________________________________
cont/
PIR North Coast NSW Application Form Mar 2014
Daily living
Housing
Income Support
Education/Training
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Please list services which are providing support for you (if any) and write yes or no as consent for us to contact them.
If you are unable to complete this information now we can follow up with you later.
Service Name
Consent to
contact Y/N
Contact Person
1.
2.
3.
4.
5.
4. Goals for participating in PIR
What are your main goals at the moment?
1._____________________________________________________________________________________________
2._____________________________________________________________________________________________
3. _________________________________________________________________________
5. Safety
Safety is very important. Please help us to understand how to make sure that safety remains a priority.
Is there some risk of:
Suicide
Self harm
Harm to others
Harm from others
Please provide details: ____________________________________________________________________________
What safety strategies are in place:___________________________________________________________________
Have you made a plan with any other services for managing safety? Yes
No
If yes please attach
6. Applicant Consent
I (applicant name),
give permission for this information to be submitted to PIR.
I understand that my details may be discussed by service providers I have given consent to in this document and at
meetings involving PIR. I also give permission for a PIR Support Facilitator to contact me. I understand I can withdraw
my consent at any time.
Signature: ______________________________________________
Date:_____________________________
7. Contact details of person completing this application
This is a self-referral (see contact details in Section 2 above)
Name: ____________________________________ Agency/Service (if appl.): ______________________________
Relationship to applicant:______________________________________________
Phone: ___________________________________ Email:______________________________________________
Signature: _________________________________________
Date: ____________________________
Thank you for completing this application. Please email the form to [email protected] or fax to
(02) 6658 7963. No further information is required from you at this stage. Your application will soon be assessed
and a local PIR Support Facilitator will be in touch with you. Please call 1800 022 066 with any further enquiries.
PIR North Coast NSW is a consortium led by Mission Australia and including Anglicare North Coast, Ballina District Community Services
Association, the Buttery, CRANES, CHESS, Galambila Aboriginal Health Service, New Horizons and On Track Community Programs.
PIR North Coast NSW Application Form Mar 2014
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