NALAG Grief Support | Self Referral Form

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Before completing this self referral form, please take a moment to review our services to determine whether Grief Support is suitable for you 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.

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Personal Information

Name(Required)

First Name Last Name

Date of Birth(Required)

Gender(Required)

Pronouns

He/Him

She/Her

They/Them

Other

Address

Street Address City State Postal Code

Email Address(Required)

Phone(Required)

Best Day To Call You(Required)

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

Best Time To Call You(Required)

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

Are you of Aboriginal or Torres Strait Islander descent?(Required)

Yes, Aboriginal

Yes, Torres Strait Islander

Yes, both Aboriginal and TSI

Are you from a culturally and/or linguistically diverse background (CALD)?(Required)

Yes

Rather not say

Do you have a disability?(Required)

Yes

Rather not say

Emergency Contact

Please provide emergency contact person that we can call in the event we cannot reach you.

Emergency Contact Name(Required)

Emergency Contact First Name Emergency Contact Last Name

Relationship to you(Required)

Emergency Contact Phone(Required)

Emergency Contact Email(Required)

Mental Health Information

NALAG may not be suitable for individuals experiencing complex mental health issues, If any of these apply to your 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.

Do you 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

Do you 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 your current medications (if any) below:

Are you 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 you thought of taking your own life?(Required)

Yes

Not Sure

Do you have a plan for taking your own life?(Required)

Yes

Not Sure

Do you have the means to take your own life?(Required)

Yes

Not Sure

Have you attempted suicide previously?(Required)

Yes

Not Sure

If yes, please provide date of last attempt:

Loss + Grief

Have you client experienced one or more of the following losses?(Required)

Death of a loved one

Seperation/Divorce

Relationship Breakdown

Pet Loss

Job Loss

Loss of home/homeland

Entering Aged Care

Loss of Identity

Other

Approximate Date of Loss

Please advise an approximate date of the loss.

Tell Us About Your Current Situation

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

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

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

Other

Terms and Conditions(Required)

By submitting this form, you acknowledge and agree that you have provided consent for NALAG Grief Support to contact you 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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Getting Help

Referrals

Referrals to NALAG Grief Support are accepted through:

Self-Referral
GP’s
Mental Health
Hospitals

Early Response

The NALAG Early Response (ER) Team is dedicated to providing immediate support to individuals affected by sudden and unexpected incidents involving injury or death. Our trained volunteers and counsellors are here to help you navigate through the initial shock and trauma.

Locations

NALAG Grief Support has branches in Dubbo, Mudgee, Hunter and Sydney regions. NALAG Head Office is located at 7 Welchman Street, Dubbo NSW 2830.

Cost

NALAG Grief Support is a not for profit organization funded by Ministry of Health. NALAG Grief Support provides loss and grief support to all people regardless of race, religion and financial circumstances and provides Grief Support FREE of charge.

Hours

NALAG Grief Support may not be available around the clock. However, we understand the importance of being accessible when you need us most. Here are our current operating hours:

Dubbo Centre for Loss & Grief:

Monday to Friday: 9:00 AM - 5:00 PM (Excluding Public Holidays)
Appointments for other times may be negotiated.

Mudgee Centre for Loss & Grief:

Tuesday and Wednesday: 10:00 AM - 3:00 PM (Excluding Public Holidays)

While we strive to respond to inquiries as swiftly as possible within our operating hours, please feel free to reach out to us through our online contact form outside of these times. We will get back to you as soon as we can during our next business hours.

Due to the individual nature of the support person and client arrangement, times may be negotiated outside of office hours for online and telephone support. This can be discussed with your when you enquire for support.

How to Reach Us

Please contact us on 02 6882 9222 and our staff will be pleased to discuss your needs and answer any questions you may have.

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Early Response

NALAG Grief Support is UNABLE to provide a crisis service.

If you or someone you know needs urgent support, please contact a crisis support service such as:

Lifeline
13YARN
Kids Helpline
Beyond Blue

Always call 000 (triple zero) in an emergency.

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About Us

Supporting Australian communities, families and individuals experiencing loss, grief and trauma for over 48 years.

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Contact

For grief Support - 13 000 GRIEF (13 000 474 33)

(02) 6882 9222

NSW Head Office, 7 Welchman Street, Dubbo NSW 2830

PO Box 379, Dubbo NSW 2830

NALAG acknowledges and pays respect to the Traditional Owners and Custodians of country throughout Australia. We honour and respect the cultural heritage, customs and beliefs of all Aboriginal and Torres Strait Islander people. We recognise that Aboriginal and Torres Strait Islander peoples have spiritual, social and cultural connections with their traditional lands and waters. We would like to express our sincerest gratitude to the communities on whose land NALAG works.

Our organisation is a place where human rights are respected and people of diverse genders and sexual orientation are welcomed and supported.

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Register Online

Personal Information

Emergency Contact

Mental Health Information

Suicide Risk

Loss + Grief

Section Break

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.

About Us

Resources

Contact