Intake Form – Confidential

Referrals are subject to approval

Please refer to our services page for criteria:

Intake Form
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Age caption
Service required
Client Legal Information
Behaviour Information
Has the client consented to this referral?
Is this a mandated referral?
Has the client consented to NINI contacting them? (NINI consent form download at the bottom of the page)
Is there an existing case/ family plan?
Can NINI access the case/ family plan?
Has the client ever had a mental health diagnosis, if so? What is the diagnosis? please add in comments
Is the client currently on any medication? If yes, what for? please add in comments.
Has the client ever attempted self-harm or suicide? please add in comments
Client Protective Factors
Best available days and times to contact the client or parent/ guardian if under 18

Please complete consent form with referral and email to info@nini.au

Thank you for the referral, please send any attachments with this referral to info@nini.au