Thorne Harbour Health LGBTIQ+ Intake

Hi there!

This is a referral form for the Thorne Harbour Health LGBTIQ+ Mental Health service in Adelaide. This should take approximately 5-10 minutes to complete. 

Please note that we are not an emergency or crisis service, if immediate support is required, please call 000, or attend at your nearest emergency department at your closest hospital. 

Details of other supports are provided on our website.

Referral basics

Your (the referrer) details

What is your organisation's name and what is your role/position? *

For example: housing, mental health, etc.

Personal details

What name would you like to be known as?

What name would the person like to be known as?

Chosen name, nickname, cultural name, alias, etc.

What is your legal name?

What is the person's legal name?

Please note that this is only for legal and record keeping purposes.

What is your date of birth?

What is the person's date of birth?

Do you have any accessibility needs you would like us to be aware of?

Does the person have any accessibility needs you would like us to be aware of?

This can include mental health, physical accessibility, sensory needs, etc.

Gender identity, sex and sexuality

What is your gender identity?

What is the person's gender identity?

Does your gender identity differ from the sex you were assigned and/or presumed at birth?

Does the person's gender identity differ from the sex you were assigned and/or presumed at birth?

What are your pronouns?

What are the person's pronouns?

For example she/her, he/him, they/them, she/they, he/they, all pronouns, etc.

Do you identify as having an intersex variation?

Does the person identify as having an intersex variation?

This is a variation in sex characteristics or reproductive organs that do not fit medical or social expectations for "male or female bodies"

What is your LGBTIQA+ identity?

What is the person's LGBTIQA+ identity?

Cultural identity

What is your country of birth?

What is the person's country of birth?

Do you identify as Aboroginal or Torres Strait Islander?

Does the person identify as Aboriginal or Torres Strait Islander?

What is your cultural and/or ethnic background?

What is the person's cultural and/or ethnic background?

Do you have any cultural or spiritual needs?

Does the person have any cultural or spiritual needs?

Would you like an interpreter?

Would the person like an interpreter?

This might be for a language other than English, AusLan, or for another reason.

Please indicate what language or type of interpreter you require.

Please indicate what language or type of interpreter the person requires.

Are you an Australian citizen or permanent resident?

Is the person an Australian citizen or permanent resident?

What sort of temporary visa are you on?

What sort of temporary visa is the person on?

Contact details

What is your address?

What is the person's address?

What is your best contact number?

What is the person's best contact number?

First contact will be made via this number unless requested otherwise

Does this number belong to you?

Does the contact number belong to the person?

Who does the number belong to, and what is their relationship with you?

Who does the number belong to, and what is their relationship with the person?

What is your email address?

What is the person's email address?

Tell us about your experience

Tell us about the person's experience

What service do you require support from?

What service does the person require support from?

What are the main areas of concern?

  • Is there someone in your life that is making you feel unsafe? (eg, physically, emotionally, socially etc)

  • Do you feel you are making someone in your life feel unsafe?

  • Include any recent/previous incidents – DV risk assessment score, copies of intervention orders, police report numbers if applicable.

What are the main issues/concerns the person requires support for?

What substance or substances are you concerned with?

What substance or substances does the person have a concern with?

Please provide information of any potential risk and/or relevant safety planning.

What other supports do you currently have (if any)?

What other people, services and/or health and community providers are currently involved in supporting the person (if any)?

Are you currently in an abusive relationship

Is the person currently in an abusive relationship?

Are you currently residing with the person causing harm?

Are they currently residing with the person causing them harm?

Are you currently experiencing any of the following?

Is the person currently experiencing any of the following?

Have you recently left an abusive relationship?

Has the person recently left an abusive relationship?

Have you had a history of domestic or family violence in the last two years?

Has the person had a history of domestic or family violence in the last 2 years?

What is your relationship to the person causing you harm?

What is the person's relationship to the person causing them harm?

e.g. domestic partner, sibling, etc.

Is there anything else you would like us to know?

Is there anything else you think we should know?

Contacting you safely

To ensure your safety, we would like to confirm the following, regarding your contact number - {{phone}}.

To ensure your safety, we would like to confirm the following, regarding your contact number - {{phone}} and email address - {{email address}}.

To ensure your safety, we would like to confirm the following, regarding your email address - {{email address}}.

Emergency contact details

Please let us know who to contact in case of an emergency

Please let us know the person's emergency contact.

What is your relationship to your emergency contact?

What is the person's relationship with their emergency contact?