Supporting Recovery Mental Health Referral Form

Supporting Recovery provides access to ongoing trauma informed mental health support, including psychological therapies, for people who have experienced family, domestic and sexual violence. It is offered at no charge for a period up to two years and in person services are available in the Fairfield, Liverpool and Campbelltown LGAs. Click here to download the Service Brochure.

Please note, Supporting Recovery is not a crisis support service. If someone is in urgent need of help, contact 000. If they require a crisis response contact NSW Mental Health Access Line on 1800 011 511; 1800RESPECT on 1800 737 732 or NSW DV Line on 1800 656 463.

Supporting Recovery accepts referrals from agencies in South Western Sydney area (predominantly in Fairfield, Liverpool, Campbelltown) and self-referrals from people that live and/or work in South Western Sydney area.

If you need to speak with someone from the Supporting Recovery team about this referral, please get in touch using the contact details below:

Email: referrals@supportingrecovery.org.au
Phone: 1300 316 554

Client Details

Client First Name

Client Last Name

Client Address (if known)

Client Preferred Contact Method

Provide Client Preferred Contact Information (Client phone number or email address)

Is it safe to leave a message?

Client Sex

Client DOB

Is DOB an estimate?

Client Pronouns

Indigenous Status

Does the client identify as Culturally and Linguistically Diverse?

Country of Birth

Main Language Spoken at Home

Proficiency in Spoken English

Interpreter Required?

Yes No

Referrer Details

Referral Date

Referrer Name

Referrer Profession

Referrer Position Title

Referrer Organisation

Referrer Contact Phone

Referrer Contact Email

How did you hear about Supporting Recovery?

If you have selected 'Other', please provide details here

Referral Details

Has the referrer identified there is current and/or past family, domestic and sexual violence for the client being referred?

Yes No Unknown

What assistance/support does the client need?

Is the client currently experiencing an acute crisis of any kind?

Yes No Unknown

If yes please provide details

Is the client currently engaged with other support services?

Yes No

Please provide details

Is the client currently being supported with case management from your organisation or from another provider?

Yes No

Please provide details

Will case management support continue to be provided following referral to Supporting Recovery?

Yes No N/A

Client Risk Details

Have any of the following risk factors been identified as relevant for this client? (please tick all that apply)

Has a Domestic Violence Safety Assessment Tool (DVSAT) been completed?

Yes No

DVSAT Risk Level

At threat At serious threat

Date DVSAT completed

Has an Initial Assessment and Referral (IAR) been completed?

Yes No

IAR Risk Rating

Date IAR completed

Does the client have a current safety plan in place?

Yes No

Please email any completed risk assessments as a pdf document (DVSAT, IAR, Suicide Risk Screen, other) to referrals@supportingrecovery.org.au
Please ensure the email subject line includes the following: [Risk Assessment Type]; [Client Surname]; [Referral Date]
Example DVSAT; SMITH; 8.4.24

Client Preferences

Mode of Service Delivery

In person only Online only In person & Online No preference

Service Location

Fairfield Liverpool Campbelltown No preference

Client Consent

Has consented to this referral.
Has been informed of the role and services provided by the Supporting Recovery Program.
Has been informed that their information has been provided to the Supporting Recovery team in order to determine their eligibility for services and for the purposes of coordinating their care.
Has been informed that their information may be shared between the Supporting Recovery care team members across Anglicare Sydney and CatholicCare Sydney and with other relevant professionals and agencies for the purposes of coordinating their care.
Has been informed that their deidentified information may be shared with SWS Primary Health Network and NSW Department of Health for statistical and program related purposes.
Has been informed that their personal information will be collected and stored in accordance with Privacy Legislation.

Referrer Name

Referrer Signature

Date Signed

Referrals will be responded to within 5 business days of receipt.

I agree to the Supporting Recovery Privacy Policy.

If you are currently experiencing domestic violence and need crisis support, call 1800RESPECT (1800737732 ). If you are in immediate danger, call the police on 000.