Connection to Distress Support Service - Yurri Mulana

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The Distress Support Service (DSS) is a community-based program. Local people designed it to provide kind and compassionate support to people experiencing distress.

The service will assist people for 2-3 weeks to build connections. This is based on individual needs. This involves flexible ways of supporting people including in-person, by phone and online.

People can choose to connect with the Short-Term Support Service. If they do, a DSS peer worker will reach out via their preferred contact method, within 1 business day.

DSS is provided by Mind Australia in partnership with Primary Care Connect.

Date

DSS Connection Options

Accept connection to DSSDecline connection to DSS

I consent for my information to be sent to DSS *

YesNo

Please read below

If you do not understand, please speak to your Community Engagement Point worker, or contact the DSS team directly on dss@mindaustralia.org.au or (03) 4836 1100.

I understand that DSS is a free support service
More information on DSS can be found here:
https://www.mindaustralia.org.au/services/distress-support-service-yurri-mulana
I consent to the information I have provided on this form to be sent to the DSS team. My information will not be shared with anyone else.
I consent to being contacted via my preferred contact method.
You can only submit this form to connect to DSS if you tick yes.

Service name

Service Location

Who is completing this form?

Community Engagement Point WorkerMyselfFamily, carer, or loved one on behalf of someone else

Please provide your name

Please provide your contact details

Have you already spoken with a Community Engagement Point worker?

YesNo

If you can remember, what community engagement point did you go to?

Info about the person being connected to DSS

Preferred name *

Surname

Other names

Interpreter required?

YesNo

Preferred Language

Indigenous Status

Neither Aboriginal or Torres Strait IslanderAboriginal but not Torres Strait IslanderTorres Strait Islander but not AboriginalBoth Aboriginal and Torres Strait IslanderPrefer not to say

Preferred method of contact *

CallSMSEmailNo contact - connection declined

Contact details for preferred contact method *You can type telephone numbers, mobile phone numbers, or email addresses

Anything else you'd like us to know?e.g. reason for connection, support ideas, anything else you feel is important right now