Age pension Care recipient’s postcode: Veterans’ Affairs pension Care Recipient Condition (Tick all that apply) Frail aged (65+ or 50+ for indigenous) Disability support pension Dementia Carer Payment Person under 65 with a disability Carer Allowance Chronic illness Unemployment related allowance In need of palliative care Other government pension / allowance Mental illness No government income support payment Specify condition/diagnosis EMPLOYMENT Full time employed Part time employed SEEKING COUNSELLING DUE TO Not in paid employment Recent commencement of caring role Unemployed allowance of care recipient Retired Negative change in condition of care recipient LENGTH OF TIME AS Negative change in health of carer Less than 2 years Care recipient to residential care 2–4 years Financial strain 5–9 years Change in household composition 10–24 years Ongoing stress of carer role More than 25 years Other CARER ROLE Primary carer Signature of person completing form Other carer CARE RECIPIENT DETAILS Carer consent: I consent to the information disclosed on this form being provided to Carers Victoria for the purposes of referral and Number of care recipients assessment for counselling services and inclusion in de-identified data If there are more than two care recipients, please include their reporting. I understand that Carers Victoria may contact me in relation to information on a separate piece of paper. this referral and conduct further assessment. Care Recipient 1 Further information on Carers Victoria’s Privacy Policy is available at Care recipient’s relationship to carer Signature of Care recipient’s age Is care recipient living with carer? Or verbal consent obtained by: Care recipient’s postcode Name Care Recipient Condition (Tick all that apply) Date of verbal consent Frail aged (65+ or 50+ for indigenous) Dementia Mail to: Fax to: Person under 65 with a disability NCCP (03) 9396 9595 Chronic illness Carers Victoria PO Box 2204 In need of palliative care FOOTSCRAY VIC 3011 Mental illness Email: For referral enquiries call Carer Advisory Line on 1800 242 636 Specify condition/diagnosis CARE RECIPIENT DETAILS (continued) Care Recipient 2 Care recipient’s relationship to carer: Care recipient’s age: Is care recipient living with carer?:
Age pension Veterans’ Affairs pension Disability support pension Carer Payment Carer Allowance Unemployment related allowance Other government pension / allowance No government income support payment EMPLOYMENT Full time employed Part time employed Not in paid employment Unemployed allowance Retired LENGTH OF TIME AS Less than 2 years 2–4 years 5–9 years 10–24 years More than 25 years CARER ROLE Primary carer Other carer CARE RECIPIENT DETAILS Number of care recipients If there are more than two care recipients, please include their information on a separate piece of paper. Care Recipient 1 Care recipient’s relationship to carer Care recipient’s age Is care recipient living with carer? Care recipient’s postcode Care Recipient Condition (Tick all that apply) Frail aged (65+ or 50+ for indigenous) Dementia Person under 65 with a disability Chronic illness In need of palliative care Mental illness Specify condition/diagnosis CARE RECIPIENT DETAILS (continued) Care Recipient 2 Care recipient’s relationship to carer: Care recipient’s age: Is care recipient living with carer?: Care recipient’s postcode: Care Recipient Condition (Tick all that apply) Frail aged (65+ or 50+ for indigenous) Dementia Person under 65 with a disability Chronic illness In need of palliative care Mental illness Specify condition/diagnosis SEEKING COUNSELLING DUE TO Recent commencement of caring role of care recipient Negative change in condition of care recipient Negative change in health of carer Care recipient to residential care Financial strain Change in household composition Ongoing stress of carer role Other Signature of person completing form Carer consent: I consent to the information disclosed on this form being provided to Carers Victoria for the purposes of referral and assessment for counselling services and inclusion in de-identified data reporting. I understand that Carers Victoria may contact me in relation to this referral and conduct further assessment. Further information on Carers Victoria’s Privacy Policy is available at Signature of Or verbal consent obtained by: Name Date of verbal consent Mail to: NCCP Carers Victoria PO Box 2204 FOOTSCRAY VIC 3011 Fax to: (03) 9396 9595 Email: For referral enquiries call Carer Advisory Line on 1800 242 636
NCCP-referral%20form-march%202016-final.docx