The Luminos Project Pre-intake Form - Ruah Community Services

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The Luminos Project Pre-intake Form

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The Luminos Project Pre-intake Form

Fill out the The Luminos Project online pre-intake form and one of our staff will be in touch to organise an initial phone consultation with you.

Full legal name(Required)

Preferred name(Required)

DOB(Required)

DD slash MM slash YYYY

Country of Birth(Required)

Do you identify with any particular cultural groups?(Required)

Yes

No

This field is hidden when viewing the form

Do you identify with any particular cultural groups?

Do you identify with any particular cultural groups?

What cultural group do you identify as?(Required)

Pronouns(Required)

Gender(Required)

Contact number(Required)

Email(Required)

Address(Required)

Living arrangement(Required)

Employment status:(Required)

Not stated(Required)

Emergency Contact

Relationship(Required)

Phone number(Required)

Can you confirm that the person listed is a responsible adult?(Required)

Yes

No

Is this person aware that you have listed them as an emergency contact, and that they may be contacted in case of an emergency?(Required)

Yes

No

Preferred time to be contacted:(Required)

Morning

Afternoon

Weekend

No Preference

Preferred Language(Required)

Preferred Communication Method(Required)

Other(Required)

Was this form completed by the young person?(Required)

Yes

No

Who referred you (If self-referring please write N/A)?(Required)

Has the young person consented to us contacting them directly?(Required)

Yes

No

Referrer name:(Required)

(and service if applicable)

Referrer contact details:(Required)

How did you hear about the service?(Required)

Please indicate where you heard about the service(Required)

Please indicate the name of the Mental Health Service(Required)

All information shared during our intake process is confidential. Where risk of harm to yourself or someone else is identified, you understand that confidentiality may be broken in order to keep you &/or someone else safe. Where this is the case, staff will let you know and endeavour to collaborate with you around how this will happen.(Required)

I understand and agree.

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Ruah Community Services supports and empowers vulnerable and disadvantaged people so they can create meaningful change in their lives.

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13 78 24

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[email protected]

29 Shenton St, Northbridge, WA, 6003

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Ruah acknowledges and respects the Traditional Aboriginal and Torres Strait Islander Custodians/Owners of the land on which we work, live and build our lives, families, and communities. We pay our respects to the First Peoples of this country, their cultures and Elders past and present.

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