NALAG Grief Support | Agency Referral Form

Agency Referral

Before completing this referral form, please take a moment to review our services to determine whether the client is suitable for support through our agency. This ensures we can provide the most appropriate and effective assistance. If you require any guidance or have questions during this process, please don’t hesitate to contact us on (02) 6882 9222. or email rego@nalag.org.au

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Referring Agency Information

Referring Agency/ Organisation Name(Required)

Referring Agency Contact Details(Required)

Agency Contact First Name Agency Contact Last Name

Referring Agency Email Address(Required)

Enter Email Confirm Email

Referring Agency Contact Phone(Required)

Client Information

Client's Name(Required)

Client's First Name Client's Last Name

Client Date of Birth(Required)

DD slash MM slash YYYY

Client Gender(Required)

Client Pronouns

He/Him

She/Her

They/Them

Other

Client Address

Street Address City State Postal Code

Client Email Address(Required)

Client Phone(Required)

Is the client being referred a child?

Yes, please provide Carer Contact details.

Carers Contact Name

First Last

Carers Phone

Carers Email

Best Day To Call Your Client(Required)

When is the best day for us to reach your client via telephone?

Best Time To Call Your Client(Required)

When is the best time for us to reach your client via telephone?

Is the Client of Aboriginal or Torres Strait Islander descent?(Required)

Yes, Aboriginal

Yes, Torres Strait Islander

Yes, both Aboriginal and TSI

Is the client from a culturally and/or linguistically diverse background (CALD)?(Required)

Yes

Rather not say

Does the Client have a disability?(Required)

Yes

Rather not say

Emergency Contact

Please provide emergency contact person for the client other than yourself, that we can call in the event we cannot reach the client.

Emergency Contact Name(Required)

Emergency Contact First Name Emergency Contact Last Name

Relationship to Client(Required)

Emergency Contact Phone(Required)

Emergency Contact Email(Required)

Client Mental Health Information

NALAG may not be suitable for individuals experiencing complex mental health issues, If any of these apply to your clients situation, we recommend reaching out to a mental health professional or specialist service better suited to provide the level of care required. Please call NALAG 02 6882 9222 during office hours to discuss before proceeding with this referral.

Does the client have any of the following mental health issues?(Required)

Prolonged Grief Disorder (PGD)

Complex PTSD

Bipolar Disorder

Borderline Personality Disorder

Schizophrenia

Active suicidal thoughts

Substance Dependence

History of psychosis

Recent admission to mental health inpatient unit (within 12 months)

Other

Does the client have any of the following mental health issues?

Mild to Moderate Depression

Mild to Moderate Anxiety

Behavioural issues (ADAHD etc).

Other

If yes, has the condition been diagnosed?

Yes

Not sure

Please list the Clients medications (if any) below:

Is the client seeking assistance from any other agency or practitioner?

If Yes, please list below:

Suicide Risk

NALAG’s support services may not be suitable for individuals who have active suicidal thoughts or behaviours.

Has the Client thought of taking their own life?(Required)

Yes

Not Sure

Does the Client have a plan for taking their own life?(Required)

Yes

Not Sure

Does the Client have the means to take their own life?(Required)

Yes

Not Sure

Has the Client attempted suicide previously?(Required)

Yes

Not Sure

If yes, please provide date of last attempt:

MM slash DD slash YYYY

Do you have any concerns for the client's safety?(Required)

Yes - please call NALAG on 02 68829222 to discuss your clients suitability.

Loss + Grief

Has your client experienced one or more of the following losses?(Required)

Death of a Minor {>15 yrs)

Death of loved one

Domestic Violence

Family Breakdown

Isolation

Loss of home (fire)

Pre/Post Natal Loss

Loss of Identity

Rural Loss

Suicide

Other

Approximate Date of Loss

Please advise an approximate date of the loss.

MM slash DD slash YYYY

Tell Us About Your Clients Current Situation

Please provide a brief description of what your client may be experiencing right now ie: "My client's father has recently died". This will help us assist your client better.

Please provide any relevant information that may assist us in providing the appropriate support.

Client's Preferred type of Grief Support(Required)

Face-to-face Grief Support

Telephone Grief Support

Online Grief Support (Zoom Video Call)

Group Grief Support (face-to-face)

Group Grief Support (online)

How did you hear about NALAG's Grief Support Service?(Required)

Google

Social Media ie Facebook/Instagram

GP or related Service

Radio

Word of Mouth

Community Mental Health

Dept Communities & Justice (GP)

Employer

Family + Friends

Griefline

Lifeline

Mission Australia

NALAG Volunteer

NALAG Website

NSW Health (Hospital/AgedCare)

Orana Support Service

Returning Client

School

Social Media

Uniting Care

Other

Terms and Conditions(Required)

By submitting this form, you acknowledge and agree that your client has provided consent for NALAG Grief Support to contact your client using the information provided. This may include communication via phone, email, or other means, as relevant to your inquiry.

I agree to the terms and conditions.

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Agency Referral

Referring Agency Information

Client Information

Emergency Contact

Client Mental Health Information

Suicide Risk

Loss + Grief

Getting Help

Referrals

Early Response

Locations

Cost

Hours

How to Reach Us

NALAG Grief Support is UNABLE to provide a crisis service.

Lifeline

13YARN

Kids Helpline

Beyond Blue

Always call 000 (triple zero) in an emergency.

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