CONFIDENTIAL
ADULT Referral to Phoenix Centre Services	
Phoenix Centre services are available to people from a refugee background with a history of torture and trauma prior to arrival in Australia, who are experiencing psychological / psychosocial difficulties believed to be associated with their experience of torture and trauma. Please contact the Phoenix Centre for more information.	

SERVICE REQUIRED (please ‘X’ appropriate box)	
	Counselling (North and South)		Natural Therapies (South only)	
The Phoenix Centre is not a crisis service and is not able to respond immediately
For urgent assistance, please contact Lifeline on 13 11 14 or the Mental Health Helpline on 1800 332 388

REFERRER DETAILS (fields marked with an * must be completed)	
*Date: <FormattedDate>	Referring Organisation: <Practice>	
*Name of Referrer: <UsrName>	Email: 	
*Contact number: <UsrPhone>	

CLIENT INFORMATION (fields marked with an * must be completed)	
*Family name/s: <PtSurname>	Given name/s: <PtFirstName> <PtMidName>	
*Gender: <PtSex>	Date of birth: <PtDoB>	
*Full address: <PtStreet>, <PtCity>, <PtPostcode>	
*Main number: <PtPhoneMob>	Additional number: <PtPhoneH>	
Best time to phone:	AM: 	PM: 	Any: 	Email: 	
*Date of arrival: 	*Country of birth: 	
Ethnicity/religion: <PtEthnicity>	*Preferred language/s: 	
*Interpreter required: 	*Interpreter gender: 	

RESIDENTIAL STATUS (‘X’ appropriate box)	
Permanent Resident: 		Yes		No	Visa type: 	
Australian Citizen:		Yes		No	
Asylum seeker:		Community detention		BVE		Other: 	
Support agency: 	DIBP boat ID: 	DIBP client ID: 	
Temporary visa:		TPV		SHEV		Other: 	

FAMILY MEMBERS RESIDING WITH CLIENT	
Name/ Relationship	Age	Gender	Are you concerned about this person?	
				Yes		No	
				Yes		No	
				Yes		No	
				Yes		No	

REASONS FOR REFERRAL (please attach additional page if necessary)	

	

Please ‘x’ and describe if any of the following are present 	
Person discloses experience of torture or other traumatic events. 		Comments:
	
Person discloses injuries or pain which is/are the result of torture, sexual assault or other form of violence. 		Comments:
	
Person discloses suicidal ideation or self harm [Note: Please refer to an emergency service if an immediate risk] 		Comments:
	
Person is seeking referral as a result of family relationship difficulties		Comments:

Psychological screening: Observations (no questions required) or spontaneous disclosures of
History or presence of the following issues (‘X’ all that apply)	
	Crying a lot		Intense/persistent emotional distress	
	Aggressive behaviour or persistent anger		Phobias: e.g. fear of going out/fear of groups	
	Repeated expressions of hopelessness		On alert for things going wrong	
	Severe social withdrawal or appears uncommunicative		Overreacting to noises, etc. in environment	
	Peculiar appearance, behaviour or speech		Alcohol or substance abuse	
	Not responding to needs of children, emotional distance		Poor self-care, household care	
	Persistent physical ailments with no medical cause		Signs of family conflict	
	Persistent and severe sleep difficulties, nightmares		Expressed threat to harm self or others	
	Appears disoriented, incoherent or confused		Expresses bizarre or illogical beliefs	

Person or family member discloses that he/she suffers from a mental health problem or that he/she is being treated for a mental health problem (or their words for this)		Yes		No	
Intellectual / Cognitive impairment:
(please ‘X’ a response and provide details below) 	Suspected	Assessed	Confirmed										
		Yes		No		Yes		No		Yes		No	
Details: 	
Where there is an immediate risk of harm to self or others please refer to emergency service. For non-immediate threats, please provide a description below:	

SUPPORT NETWORKS (e.g. community group, school, and other agency)	
Agency/organization/school/GP	Contact name	Contact number	

			

CONSENT (essential for all Phoenix Centre Services)	
Has the client given consent to be contacted by the Phoenix Centre		Yes		No	
Can the client be contacted directly?		Yes		No	
Has the client given consent for the Phoenix Centre to contact the referrer?		Yes		No	

Client signature:		

Referrer signature confirming Verbal Consent has been received via TIS:		

For any questions regarding completion of this form, please call 03 6221 0999
For both North and South referrals, email completed form to phoenixreferrals@mrctas.org.au 
or mail to:	
Phoenix Centre
PO Box 740 
Launceston, TAS, 7250	Phoenix Centre
1A Anfield Street
Glenorchy, TAS, 7010