Referral Form

Anyone can refer to the MATES Program. We accept self-referrals as well as referrals from medical practitioners, community members, healthcare professionals, family/friends etc. *Please note It is possible you will not be matched. This can happen for a number of reasons. If a suitable match has not been made in 2 years, you will be taken off the waiting list and may reapply for service after 2 years (this allows for equitable access to a place on the waiting list for new people entering into the program). If this is the case you are still able to attend social outings and receive the newsletter if you wish.

Eligibility

To be eligible for the MATES Program the applicant must be...

1. 18 years or older
2. Socially Isolated
3. Ready to Expand Social Networks
4. Have a mental ill health diagnosis
5. Actively working with a case manager or doctor regarding their mental health (and continue to do so during program)

Is the applicant eligible?

The applicant meets all the criteria and is eligible for the MATES program

Applicant Details

Full Name

Street Address

Suburb

Post Code

Phone Number

Date Of Birth

Country Of Birth

Main Language

Identifies As

Gender

Emergency Contact/Next of Kin

Full Name

Phone Number

Further Details

What is the applicant’s mental ill health diagnosis?

Describe in your opinion how/why the person is ready to reconnect?

Any physical conditions which should be taken into account?

Any other comments or suggestions (anything the MATES coordinator should be aware of including alerts/concerns):

Referrer Details

Full Name

Position

Agency / Organisation

Office Address

Office Phone

Office Mobile

Office Email

Will you be involved in the ongoing care of the participant?

Would the referrer or the referring agency like to be present at the first meeting between the MATES Coordinator and the applicant, if the applicant agrees?

Ongoing Mental Health Care Professional Details

(Doctor, Psychologist, Psychiatrist)

Full Name

Position

Agency / Organisation

Office Address

Office Phone

Office Mobile

Office Email

Would the referrer or the referring agency like to be present at the first meeting between the MATES Coordinator and the applicant, if the applicant agrees?

Submit

Referrals will not be accepted without adequate information regarding professional network of support and all details completed.

Date

If you prefer a paper version of the referral form or simply don’t like online forms you can download a PDF version below

MATES

Referral Form

Eligibility

To be eligible for the MATES Program the applicant must be...

Applicant Details

Emergency Contact/Next of Kin

Further Details

Referrer Details

Ongoing Mental Health Care Professional Details

(Doctor, Psychologist, Psychiatrist)

Submit

Forms & Documents

Contact Information