Psychosocial Support & Referral Form

Full Name*

Date of Birth

Contact Number*

Email Address

Address:

Preferred Contact Method Preferred Contact MethodPhoneEmailOther

Please specify other contact method:

Primary Diagnosis* Primary Diagnosis*Huntington's diseaseAt-RiskOther

Please Specify Other Diagnosis (as relevant)

Name of Referrer*

Organisation/Relationship to Client:

Referrer's Contact Number*

Referrer's Email Address*

Reason for Referral* Reason for Referral* Comprehensive Wellbeing Assessment – A thorough evaluation of how Huntington’s disease is affecting the individual’s daily life, relationships, mental health, and ability to manage responsibilities. This assessment helps identify the right support services.Reason for Referral Personalised Care & Support Planning – Development of a customised care plan that considers medical needs, emotional well-being, social connections, and practical support to enhance quality of life. Emotional & Psychological Support – Guidance and support to help individuals and families cope with the stress, grief, anxiety, and emotional challenges that can arise with Huntington’s disease. Accessing Services & Advocacy – Assistance in navigating complex systems such as the National Disability Insurance Scheme (NDIS), disability support, healthcare, legal rights, housing, and financial aid, ensuring individuals receive the appropriate services they are entitled to. Support for Families & Carers – Evaluation of carer needs and capacity, offering education on Huntington’s disease, improving family dynamics, and planning for long-term care to reduce stress and burnout. Financial & Future Planning Guidance – Help with managing financial challenges, understanding available government benefits, securing income stability, and planning for future care and legal needs. Other (please specify):

Additional information:

Current Services Involved (e.g., NDIS, Aged Care, Mental Health Services):

Specific Concerns or Needs:

Urgency of Referral* Urgency of Referral* Routine Urgent

Consent * Consent * By submitting this form, I confirm my consent to the referral and understand that Huntington's Victoria may contact me to discuss available support services.