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Client information

Client name

*

Gender ID

Gender description

*

Date of birth

**

Address

*

Person without a home

Person without a home NoPerson without a home Yes

Bail address (if different from above)

*

Email

**

Client does not have / have access to an email

Client does not have / have access to an email NoClient does not have / have access to an email Yes

Phone number

*

Client does not own / have access to a phone

Client does not own / have access to a phone NoClient does not own / have access to a phone Yes

CourtLink ID

*

Has the client consented to engage in a case management program and regular court reviews including judicial monitoring.

Has the client consented to engage in a case management program and regular court reviews including judicial monitoring. NoHas the client consented to engage in a case management program and regular court reviews including judicial monitoring. Yes

Referrer information

Referred by

Name of referrer

*

Is the legal representative aware of this referral?

Is the legal representative aware of this referral? NoIs the legal representative aware of this referral? Yes

Name of legal representative (if not referrer)

*

Representative phone

*

Representative email

**

Current charges

*

Court location

Next hearing date

**

Next hearing type

*

Status

Client status

Prison location

*

Program

Client program

Eligibility Criteria

Does the client meet this eligibility criteria?

Does the client meet this eligibility criteria? NoDoes the client meet this eligibility criteria? Yes

Diagnosed mental health condition or cognitive impairment

Diagnosed mental health condition or cognitive impairment NoDiagnosed mental health condition or cognitive impairment Yes

Intention to plead guilty?

Intention to plead guilty? NoIntention to plead guilty? Yes

Is the client currently in custody?

Is the client currently in custody? NoIs the client currently in custody? Yes

Reason for referral

Diagnosis or suspected / suggested diagnosis.

*

How does this condition substantially reduce the clients capacity to manage their; self-care, self-management, social interaction and/or communication?

*

What are the clients identified support needs?

*

What supports are currently in place?

*

Custody/pertinent vulnerability factors

Aboriginal and Torres Strait Islander

Aboriginal and Torres Strait Islander NoAboriginal and Torres Strait Islander Yes

LGBTQIA+

LGBTQIA+ NoLGBTQIA+ Yes

First offence

First offence NoFirst offence Yes

First time in custody

First time in custody NoFirst time in custody Yes

Aged 18-21

Aged 18-21 NoAged 18-21 Yes

Aged 22-25

Aged 22-25 NoAged 22-25 Yes

Older (over 65)

Older (over 65) NoOlder (over 65) Yes

Have you attempted to refer client to Youth Justice?

Have you attempted to refer client to Youth Justice? NoHave you attempted to refer client to Youth Justice? Yes

Interpreter required

Interpreter required NoInterpreter required Yes

Language required

*

Mental health

Mental health NoMental health Yes

Physical impairment

Physical impairment NoPhysical impairment Yes

Cognitive impairment

Cognitive impairment NoCognitive impairment Yes

Other vulnerabilities

*

Presenting Needs

Suicide ideation

Suicide ideation UnknownSuicide ideation YesSuicide ideation No

Family violence

Family violence NoFamily violence Yes

Applicable for

FV Charges

FVIO in place?

FVIO in place? NoFVIO in place? Yes

AOD

AOD NoAOD Yes

Gambling/financial

Gambling/financial NoGambling/financial Yes

Chronic health condition

Chronic health condition NoChronic health condition Yes

Caring responsibilities

Caring responsibilities NoCaring responsibilities Yes

Culturally and linguistically diverse

Culturally and linguistically diverse NoCulturally and linguistically diverse Yes

Other

*

Background

Previous CISP involvement?

Previous CISP involvement? UnknownPrevious CISP involvement? YesPrevious CISP involvement? No

Previous ARC involvement?

Previous ARC involvement? UnknownPrevious ARC involvement? YesPrevious ARC involvement? No

Previous MHARS involvement

Previous MHARS involvement UnknownPrevious MHARS involvement YesPrevious MHARS involvement No

MHARS report available?

MHARS report available? NoMHARS report available? Yes

Previous Koori liaison officer involvement?

Previous Koori liaison officer involvement? UnknownPrevious Koori liaison officer involvement? YesPrevious Koori liaison officer involvement? No

Previous drug court involvement

Previous drug court involvement UnknownPrevious drug court involvement YesPrevious drug court involvement No

Is the client currently on a CCO with treatment?

Is the client currently on a CCO with treatment? UnknownIs the client currently on a CCO with treatment? YesIs the client currently on a CCO with treatment? No

Are they in contravention?

Are they in contravention? NoAre they in contravention? Yes

Are they currently actively engaging with their CCO?

Are they currently actively engaging with their CCO? NoAre they currently actively engaging with their CCO? Yes

Has the matter commenced in BaRC?

Has the matter commenced in BaRC? UnknownHas the matter commenced in BaRC? YesHas the matter commenced in BaRC? No

Is this matter in the Indictable crime/committal stream

Is this matter in the Indictable crime/committal stream UnknownIs this matter in the Indictable crime/committal stream YesIs this matter in the Indictable crime/committal stream No

Is the client subject to an interstate order?

Is the client subject to an interstate order? UnknownIs the client subject to an interstate order? YesIs the client subject to an interstate order? No

Please describe the interstate order

*

Is this client charged with a sex offence?

Is this client charged with a sex offence? UnknownIs this client charged with a sex offence? YesIs this client charged with a sex offence? No

Is this client subject to an FVIO?

Is this client subject to an FVIO? UnknownIs this client subject to an FVIO? YesIs this client subject to an FVIO? No

Is this client currently engaged with other services? (provide details)

*

Current/alleged breaches

Are there any factors that indicate a phone or online assessment would not be suitable for this person? (provide details)

Are there any factors that indicate a phone or online assessment would not be suitable for this person? (provide details) NoAre there any factors that indicate a phone or online assessment would not be suitable for this person? (provide details) Yes

Please Describe

*

Related Documents

Remand summary

Remand summary NoRemand summary Yes

Prior criminal history

Prior criminal history NoPrior criminal history Yes

Professional reports

Professional reports NoProfessional reports Yes

CMI Forensicare/MHARS

CMI Forensicare/MHARS NoCMI Forensicare/MHARS Yes

CCO contravention reports

CCO contravention reports NoCCO contravention reports Yes

Comments

Comments

*

Please provide supporting document.

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The accused person must be diagnosed with one or more of the following:

A mental illness
An intellectual disability
An acquired brain injury
An autism spectrum disorder
A neurological impairment, including but not limited to dementia.

The diagnosis listed above must cause substantially reduced capacity in at least one of the areas of:

Self-care
Self-management
Social interaction
Communication

The accused person must benefit from receiving coordinated services in accordance with an individual support plan. Services may include:

Psychological services
Welfare services
Health services
Mental health services
Disability services
Drug treatment services or alcohol treatment services
Housing and support services
Other services that aim to reduce the risk of offending or re-offending

For more information about eligibility, refer to Section 4T of the Magistrates' Court Act 1989