Think WISE Referral Form

Resident Details

Name(Required)

First Last

Date of Birth(Required)

Gender(Required)

Male

Female

Other

Residential Aged Care Facility(Required)

Does the resident identify as any of the following

Aboriginal

Torres Strait Islander

Culturally & Linguistically Diverse (CALD)

LGBTIQ

Primary Language

If other than English

Referrer Details

Name(Required)

First Last

Role

Phone(Required)

Email(Required)

Reason for referral(Required)

Anxiety

Behavioural Issues

Grief & Loss

Carer/Family Distress

Depression

Trauma

Adjustment Difficulties

Other

Other(Required)

Brief description of presenting concern(Required)

Current supports(Required)

For example: GP, Psychiatry, Social Work

Relevant history

Past mental health diagnosis

If applicable

Any past mental health treatment

If applicable

Current health

General health conditions(Required)

Cognitive functioning(Required)

Normal decline

Mild decline

Major decline

Dementia (diagnosed)

Dementia type

Specify type if known

How does cognitive decline affect resident?(Required)

Risk assessment

Does resident have a history of aggression towards staff?(Required)

Yes

Please provide details(Required)

Consent & Privacy

Is this resident able to consent to this referral?(Required)

Yes

Have they consented to this referral?(Required)

Yes

Is there an Enduring Power Of Attorney in place? And if yes, does this cover health care (including psychological treatment)(Required)

Yes

Details of Enduring Power of Attorney providing consent(Required)

Please include if it has been enacted or not.

Data Collection and Privacy Policy(Required)

Think Mental Health Pty Ltd collects the details you provide to respond to your Think WISE referral. You may choose how much information to share. Some information may include health details, which we handle securely under the Privacy Act 1988 (Cth).

For more on how we manage your information, see our Think Mental Health Community Services Privacy Policy or contact wise@thinkmh.com.au.

I agree to the privacy policy and data collection terms.

Private Practice

Community services