Personal Focus Form

Section 1

Personal Focus is available to persons with lived experience of Mental Illness & between the age of 16 & 65. We are required by our funders to gather the following information for statistical purposes & to confirm eligibility to attend Personal Focus.
Missing information & documentation will slow down the referral process & your ability to attend the service.

I give permission for Ember to approach my clinical provider/general practitioner/support worker for further information if necessary. This information will be kept confidential along with other personal records, as required by the Health Information Privacy Code (1993).

Section 2

Support Person / Service Details

Additional Information