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About Us
- Governance
- Our Team
- Our Journey
- Impact
- Our Events
Get Involved
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Referral Form

Online Forms

Download offline form

"*" indicates required fields

I. Referrer Information

Case Worker:*

First

Date:*

Month

Day

Year

Client name:*

First

Date of birth:*

Month

Day

Year

Phone numbers:*

Gender Identity/Preferred pronoun:*

Are you homeless:*

No

Yes

If yes, for how long:

Address prior to most recent episode of homelessness:*

Current Address:*

Are you living at this address now?*

No

Yes

Current source of income:*

ADF/NDIS membership?*

Student Status:*

Country of birth:*

ATSI or CALD*

No

Yes

Referred by:*

Referrer Phone Number

Rehab History (previous rehab of minimum 4 weeks essential)

Rehab History

When

Where

How Long?

Other

Email*

Partner:*

First

Children*

First

Current children's career:*

FACS involvement in family:*

Legal History:*

Pending court dates and details:*

Current AVOs*

Yes

No

II. AOD History

In this section please describe the history of AOD usage. Include type of drug/alcohol, frequency, length of use and any other relevant information.

Drug(s) of choice

Have you used today?*

Yes

No

(If yes do not proceed with assessment)

Rehab History (previous rehab of minimum 4 weeks essential)

When

Where

How long?

Other

Current substance use

Are you abstinent:*

Yes

No

If no, for how long:

Detox:

Phone:

List

Drug/Substance

Duration

Last used

Support Network

Friends

Family

NA/AA

Counsellor

Do you have a mental health diagnosis?*

Yes

No

Are you taking your prescribed medication?*

Yes

No

List

Diagnosis

Doctor

Medication & Dosage

How Long?

Have you been in hospital, prison or a psychiatric ward in the last 12 months?*

Yes

No

If yes, Tell us the details:

Do you have a history of self-harm?*

Yes

No

III. Medical History

Have you had any major or chronic illnesses, accidents in the past or current physical medical conditions?*

Yes

No

List

Diagnosis

Doctor

Medication & Dosage

How Long?

Have you ever been diagnosed with an eating disorder?*

Yes

No

If yes, Tell us the details:

Are you pregnant?*

Yes

No

If yes, Tell us the details:

IV. Assessment Summary and Outcome

Suitable for Detour House?*

Yes

No (please complete Referral to other service and discuss with General Manager)

Discharge Summary provided?*

Yes

No

Place on Waiting List?*

Yes, pending receipt of discharge summary

No (please complete Referral to other service)

Further pre-admission information required?*

Yes

No

Details:

Referral to other service:

Additional comments:*

Number

Phone

This field is for validation purposes and should be left unchanged.

At Detour House Inc., our mission is clear: to empower women, girls, and gender non-binary individuals through the delivery of trauma-informed safe places and tailored programs, with the ultimate goal of reducing the incidence of homelessness.

Phone:
Detour House 02 9660 4137
The Girls Refuge 02 9564 3638
PO Box 253, Glebe NSW 2037

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