Partners In Recovery – Referral Form
SOUTHERN ADELAIDE-FLEURIEU-KANGAROO ISLAND
Email pir@lwb.org.au or Fax to 08 8186 0107 (secure fax line)
Please complete all information on the Referral Form
If you have any questions please phone the Partners In Recovery Team on 8307 2800
Date: _____ / ______ / 20
First Name/s: _____________________________ Surname: _________________________________
Date of Birth: ______ / ______ / ______ _____ Age: __________ years
Gender: Male ☐ Female ☐ Other ☐
Address: __________________________________________________________________________
Suburb: ____________________________________________________ Postcode:______________
Phone/s - Home: _________________ Mobile: _________________ Work:_____________________
QUESTIONS FOR THE CLIENT
REASON(S) FOR REFERRAL TO PARTNERS IN RECOVERY:
Please list any organisations you have contact with for support:
Agency:
Agency:
Contact Name:
Contact Name:
Phone/email:
Phone/email:
Agency:
Agency:
Contact Name:
Contact Name:
Phone/email:
Phone/email:
Partners in Recovery
Life Without Barriers
2/90 Beach Rd Christies Beach SA 5165
T: 08 8307 2800
F: 08 8186 0107
e: pir@lwb.org.au
Do you have concerns with any of the following areas? If Yes, please indicate current supports and
whether they meet your needs:
Physical Health ☐ Yes ☐ No
Mental Health ☐ Yes ☐ No
Housing ☐ Yes ☐ No
Alcohol and other drugs ☐ Yes ☐ No
Employment and Education ☐ Yes ☐ No
Partners in Recovery
Life Without Barriers
2/90 Beach Rd Christies Beach SA 5165
T: 08 8307 2800
F: 08 8186 0107
e: pir@lwb.org.au
Social / Community Connections ☐ Yes ☐ No
Legal / Financial / Income Support ☐ Yes ☐ No
Family / Relationships / Domestic Violence ☐ Yes ☐ No
Are you of Aboriginal but not Torres Strait Islander origin? Yes ☐ No ☐
Are you of Torres Strait Islander but not Aboriginal origin? Yes ☐ No ☐
Are you of both Aboriginal and Torres Strait Islander origin? Yes ☐ No ☐
Are you of neither Aboriginal or Torres Strait Islander origin? Yes ☐ No ☐
Is English your first language? Yes ☐ No ☐
If No, do you require an interpreter? Yes ☐ No ☐ Language: ________________________________
Are you participating in the National Disability Insurance Scheme? Yes ☐ No ☐
Have you been diagnosed with a mental illness? ☐ Yes ☐ No
How long have you have been living with a mental illness? ________________________________________
Do you have a GP? ☐ Yes ☐ No If Yes, Dr’s name: ________________________________________________
Dr’s Address / Clinic Name (if known): ____________________________________________________
Partners in Recovery
Life Without Barriers
2/90 Beach Rd Christies Beach SA 5165
T: 08 8307 2800
F: 08 8186 0107
e: pir@lwb.org.au
Type of Referral:
☐ Self (please go to Client Consent section below)
☐ Agency Referral (please complete the Risk Assessment, Referrer & Client Consent sections below)
If you are referring a client to Partners In Recovery, please complete the following information:
1. RISK OF HARM TO SELF
2. RISK OF HARM TO OTHERS
3. LEVEL OF SUPPORT AVAILABLE






None (No thoughts or action
of harm)
Low (Fleeting suicidal
thoughts but no plans/current
low alcohol or drug use)
Moderate (current thoughts/
distress/ past actions without
intent or plans/ moderate
alcohol or drug use)
Significant (current thoughts/
past impulsive actions/
recent impulsivity/ some
plans, but not well
developed/ increased
alcohol or drug use)

Extreme (current thoughts
with expressed intensions/
past history/ plans/ unstable
mental illness/ high alcohol or
drug use, intoxicated/ violent
to self/ means at harm to
harm self)




None (No thoughts or actions of
harm)
Low (Fleeting "harm to others"
thoughts but no plans/ current
low alcohol or drug use)
Moderate (current thoughts/
distress/ past actions without
intent or plans/ moderate alcohol
or drug use)
Significant (current thoughts/
past impulsive actions/ recent
impulsivity/ some plans, but not
well-developed/ increased
alcohol or drug use)
Extreme (current thoughts with
expressed intensions/ past
history/plans/ unstable mental
illness/ high alcohol or drug use,
intoxicated/violent to self/ means
at harm to harm self)




No problems/ Highly Supportive
(all aspects/ most aspects
highly supportive/ self/ family/
professional/ effective
involvement)
Moderately Supportive (variety
of support available, able to
help in times of need)
Limited Support (few sources of
help, support system has
incomplete ability to participate
in treatment)
Minimal (few sources of support
and not motivated)
No support in all areas
REFERRER:
Referrer’s Name: ___________________________________________________________________________
Referrer’s Agency & Position: _________________________________________________________________
Referrer’s Address: _________________________________________________________________________
Referrer’s Contact Phone Number/s: ________________________ Mobile: ____________________________
Referrer’s Email: ___________________________________________________
Signature of Referrer: _________________________________Date: ______ / ______ / 20 ______
CLIENT CONSENT:
Do you consent to being referred to Partners In Recovery?
☐ Yes ☐ No
Do you consent to sharing relevant information with Partners In Recovery
for the purpose of this referral? ☐ Yes
☐ No
Signature: __________________________________________ Date: ______ / ______ / 20 ______
Partners in Recovery
Life Without Barriers
2/90 Beach Rd Christies Beach SA 5165
T: 08 8307 2800
F: 08 8186 0107
e: pir@lwb.org.au