CONTACTS
Nominated support person (Next of kin / Alternative contact)
Do you have a case manager?
Do you have a guardian appointed?
Do you have a public trustee?
Which of the above is your preferred contact?
Preferred method of contact
HEALTH AND WELLBEING
Please attach a Physical Health Assessment form
Formal mental health diagnosis? If yes, please provide details.
Provide details where appropriate.
While I am a resident,if I am considered to be using drugs and alcohol which is impacting on my recovery, I agree to work with an appropriate Drug and Alcohol Service.*
Do you have any physical/health issues or disabilities (tick all that apply and provide details below):
Transgender health screens
Other (please state)
Do you have any mobility aids?
Do you take regular medication?
Do you require support taking your medication?
Do you use a Webster Pack?
Any hospital admissions in the last 12 months?
What support do you need? (Tick all that apply)
CONSENT
Term and Conditions
I acknowledge that the information provided is true and correct. I agree that BB Disability and Health Services may contact my health service providers to gather additional information to assist with my referral if needed. I consent to this referral being submitted for the consideration of BB Disability and Health Service’s residential accommodation services (support independent living - SIL). *
If you have a Guardian, please email your completed form to them to sign and email it back to you. Once you’ve received the signed copy back, please email the form to your healthcare professional to finalise and submit.
