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Client Details:
First Name: Last Name:
Address:
Address:
City:
State: Post Code:
Postal/Shipping Address:
Click if As Above
Address:
Address:
Post City:
State: Post Code:
Client Details:
DOB: Indigenous Status:
Gender: Country of Birth:
Language:    
School:  
Living Arrangements: Child Protection Client Status:
Source Of Referral: Client Service Type:
Reason For Referral: Client Group:
Referral Date: dd/mm/yyyy Closed Date:
Counsellor: Reason for Closure:
Unprogressed: Drop-In:
Pre-School: Consent for Govt to Contact:
Highest Schooling: Receiving Centerlink?
Marital Status: Active?:
       
Who Received Service:  Client  Partner  Family  Friend  Parent/Carer
Contacts:
Phone: Mobile:
Email:
Comments:
Disabilities:
 Intellectual / Learning     None
 Not Stated / Inadequately Described     Other
 Physical / Diverse     Psychiatric
 Sensory / Speach 
Other Identified Issues:
 Aggressive Behaviours     Anger
 Anxiety     Attachment Disorder
 Bullying     Criminal Involvement
 Depression     Dissociation
 Domestic Violence     Drug / Alcohol Misuse
 Eating Disorder     Employment Problems
 Financial     Flashbacks
 Grief     Housing
 Interpersonal Relationships     Isolation
 Loneliness     Low Self-Esteem
 Mistrust     Nightmares
 Parenting Skills     Phobias
 Poor Impulse Control     Post - Trauma
 Problematic Sexual Behaviours     Revictimisation
 School Problems     Self Harming Behaviour
 Sexual Dysfunctions     Sexuality
 Sexually Abusive Behaviours     Sleep Disturbances
 Somatic Complaints     Suicidal Ideation / Behaviours
 Witness to Domestic Violence 
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Client Status:
 Improved Life Skills  Support Still Required
Therapeutic Interventions:

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Date: Thu, July 2, 2020 For: Arranging Referrals Time: 15  Edit
Notes: Emailed Referrer advising Katherine not wanting to proceed with counselling at this stage.(attached). Advised allocated counsellor aswell (attached). JF

Date: Wed, July 1, 2020 For: Arranging Referrals Time: 10  Edit
Notes: Contacted Katherine was aware of referral. Didnt want to proceed at this stage of time. JF

Date: Mon, June 15, 2020 For: Arranging Referrals Time: 15  Edit
Notes: Attempted contacted; to make aware of referral; answered but was busy; contact another time. JF

Date: Fri, June 5, 2020 For: Arranging Referrals Time: 30  Edit
Notes: Received referral; acknowledge referrer (attached); created client profile; updated database and spreadsheet; emailed file to Triage MHCP folder. LG

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Referrals:

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Memos:
Date: Fri, June 5, 2020 Action Reqired: No  Edit
Memo: ROSTAS Katherine DOB - BHMH Ref 02.06.2020. LG
Document:  View Document >>  

Date: Fri, June 5, 2020 Action Reqired: No  Edit
Memo: Medical History - Katherine Rostas - 05.06.2020. LG
Document:  View Document >>  

Date: Fri, June 5, 2020 Action Reqired: No  Edit
Memo: Email Referrer - Katherine Rostas - 05.06.2020. LG
Document:  View Document >>  

Date: Thu, July 2, 2020 Action Reqired: No  Edit
Memo: Email Referrer- Katherine Kostas 2.7.2020. JF
Document:  View Document >>  

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