Step Thru Care GP / Psychiatrist referral form

About Step Thru Care 
Step Thru Care - Geelong Otway’s offers free mental health and/or alcohol and drug (AOD) support. Step Thru Care provides support in one place, which means people experiencing mental health or substance use challenges, or a combination of both, don’t need to retell their stories to multiple services. The Step Thru Care team have diverse backgrounds and expertise, including specialising in mental health, AOD and LGBTIQA+ specific challenges. This helps to create a culturally safe, accessible and inclusive service. The team is made up of mental health and AOD clinicians, child and family practitioners, multicultural practitioners, care recovery coordinators, and peer support workers who have lived experience of mental health and substance use challenges.
Step Thru Care offers a recovery focused approach by providing:
•	Education
•	Group therapies
•	Emotional support
•	Evidence-based therapies
•	Care coordination.

Eligibility Information
People who are eligible:
•	Low income, e.g. healthcare/concession card holders
•	Living rural or remote
•	People who identify as LGBTQIA+, aboriginal and/or Torres Strait Islander peoples
•	People from Culturally and Linguistic (CALD) backgrounds
•	Children under the age of 12 years
•	People experiencing perinatal depression
•	People experiencing or at risk of domestic violence
•	People with an intellectual disability and who are experiencing AOD and/or mental health issues
•	Young people who do not access to other appropriate services.
Receiving STC service is not duplicative of other services.
Those who do not fit into the above criteria should be encouraged to seek appropriate services.
Please note: people aged 12–25 should be referred to Headspace in the first instance.
Please include any supporting documentation if available, e.g. K10, IAR, SDQ

Consumer details
Title:
Full name:      
Preferred name: 
Date of birth:      
Gender:      
Pronouns:  
Address:      
☐	No fixed address
Phone / mobile:      
Email:      
Country of birth:
English proficiency:
☐	N/A – main language
☐	Very well
☐	Well
☐	Not well
☐	Not at all
Interpreter required? 
☐	Yes
☐	No
Preferred language:    
ATSI status:
☐	Aboriginal
☐	Torres Strait Islander
☐	Aboriginal and Torres Strait Islander
☐	None
Intersex:
☐	Do not wish to disclose
☐	Yes
☐	No
☐	Not stated
Sexual orientation:
☐	Bisexual
☐	Don’t know
☐	Lesbian, gay, homosexual
☐	Heterosexual
☐	Something else
☐	Not stated
Labour force status:
☐	Employed
☐	Unemployed
☐	Not in labour force
Employment participation:
☐	Full-time
☐	Part-time
☐	Not in work force
Income source:
☐	N/A – client less than 16 years
☐	Disability support pension
☐	Other pension or benefit (not super)
☐	Paid employment
☐	Compensation payments
☐	Other (super, investments)
☐	Nil income
☐	Not known
Marital status:
☐	Married 
☐	Widowed
☐	Divorced
☐	Separated
☐	Never married
Health Care Card:
☐	Yes
☐	No
NDIS participant:
☐	Yes
☐	No
Consent to share information:
☐	Yes
☐	No

Emergency or support person contact
Name:      
Relationship:      
Phone:      
Current supports
Name:      
Phone:      
Name:      
Phone:      
Child/youth referrals
Guardian name:
Number:
Does the child reside with the guardian:
☐	Yes
☐	No
If no, where does the child reside:
Carer name:
Carer number:
Are there any court orders (attach copies):
☐	Yes
☐	No
Is the child aware this referral is being made:
☐	Yes
☐	No
Referrer contact details
Name:
Profession:      
Organisation:      
Phone:      
Email:      
Suicide risk assessment
Suicide prevention referral:    
☐	Yes
☐	No
Previous suicide attempt: 
☐	Yes
☐	No
Recent attempt:      
☐	Yes
☐	No
When:      
Mental health and AOD
Principal diagnosis:
Additional diagnosis:
Legal proceedings:
☐	Yes
☐	No
Details:
Please advise of medications
Antipsychotics:
☐	Yes
☐	No
☐	Not stated
☐	Unknown
Anxiolytics:
☐	Yes
☐	No
☐	Not stated
☐	Unknown
Hypnotics:
☐	Yes
☐	No
☐	Not stated
☐	Unknown
Antidepressants:
☐	Yes
☐	No
☐	Not stated
☐	Unknown
Psychostimulants:
AOD use
Primary drug of concern:
Quantity:
Secondary drug of concern:
Quantity:
Reason for referral:
Referrer EDI Number:

Please email referral to stepthrucare@neaminational.org.au or fax to 03 5229 5286.
If you are sending via email, please ensure the document is password protected.
Please note: Step Thru Care is not a crisis service. Please call the Barwon Health ACCESS Team on 
1300 094 187 where acute risk is present.