This form needs to be completed in addition to the PMHC Referral Form
Please complete ALL areas and attach available reports or assessments
Program Inclusion Criteria - All Inclusion Criteria must be met.
The Partners in Recovery Program aims to better support people with a severe and persistent mental illness who also have complex needs and require substantial support. This program is for people who:
- Have a severe and persistent mental illness and complex needs
- Are 18 to 64 years of age
- Are not receiving, but require multiple services and support
- Need substantial assistance to engage with service
- Australian Citizen or permanent Australian Resident
1. Does the client currently have a NDIS package?
2. Is the client willing to collect the evidence required for their NDIS application?
The following SIX areas must be met (one “Yes” in each of sections 3 to 8)
4. Identifies “persistence”
5. Has complex needs that require services from multiple agencies
6. Requires substantial support/assistance to engage with services to meet their needs
7. No existing coordination arrangements in place, or arrangements have failed/contributed to issues and may be addressed by WSPIR
8. The person or their guardian is willing to participate in the PIR initiative
Secondary Contact Details
Is there any risks we should be aware of when working with this person, current or historical?
Does the client have a nominated carer or guardian?
Is the client at risk of harm to themselves or others?
Does the client have a diagnosis of a severe & persistent Mental Illness
Does the client have a history of hospitalisations due to Mental Illness?
Does the client have any secondary diagnosis e.g. Intellectual Disability, Acquired Brain Injury or Physical Disability, Diabetes, High Blood Pressure, Dental, Medication Issues, etc?
Psychosocial Support Requirements
Does the client usually need support from a person or assistive equipment in the following areas? Please provide details.
1. Communication i.e. understanding & being understood by other people?
2. Social Interaction i.e. making and keeping friends & coping with feelings and emotions?
3. Learning i.e. understanding, remembering information & learning new things?
4. Mobility i.e. getting out of bed and moving around the home & outside the home?
5. Self-care i.e. taking a bath or shower, toileting, dressing & eating, caring for own health?
6. Self-management i.e. doing daily jobs, handling money, problem solving, making decisions?
7. Is the client currently receiving any support from family, friends or formal services?
Housing, Finance, Employment
1. Current Housing Situation
2. Current Employment Status
3. Is the Client receiving Centrelink Benefits?
I. Disability Support Pension
Current Care Coordination Supports
Consider all health & community services including doctors & psychologists
Size limit for each file is 100 MB 
