REFERRAL FORM

SHIFT offers individual and group support for people experiencing a mental health concern. SHIFT supports are flexible and are tailored to your needs.

The SHIFT Program is funded by Brisbane South PHN and is available to anyone aged 18 or over and living in the Redlands, Brisbane South, Logan and Beaudesert areas who is experiencing a mental health concern and wishes to access peer support.

The SHIFT team are all peer workers who have experienced living with and working through mental health concerns. At Brook RED, we support social and emotional wellbeing and holistic recovery from mental health concerns for all people. We are welcoming and responsive to people’s needs, identities, and perspectives. We celebrate bodies, genders, sexualities, and cultures in all their diversity.

First Name *

Last Name *

Postcode *

Phone *

Email Address *

DOB *

Gender

Pronoun/s

Do you identify as LGBTQIAP+

Do you identify as Culturally or linguistically diverse

Do you identify as Aboriginal or Torres Strait Islander

Do you identify as having a disability?

How are you hoping the SHIFT program supports you? *

Are you completing this form on behalf of somebody you are supporting? *

YesNo

Brook RED is a peer service funded to help people meet their goals. As a non-clincial service we do not want to receive clinical reports, information about about medication, diagnosis, or other information not related to the goals of the person that we are supporting. Inappropriate referrals on behalf of another person may not be accepted.

Do you have consent of the person you are supporting to complete this referral, and for Brook RED to contact them? *

YesNo

Referrer's Name *

Referrer's Phone Number *

Referrer's Email address *

Preferred Contact *

Phone callTextEmail

Brook RED offers a safe, welcoming, and recovery-focused environment, and we ask that all individuals accessing our groups or individual support contribute positively to our community.

Signature: *

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Date: *

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