Darwin Indigenous Men’s Service (DIMS)
Request for Service / Referral Form
Phone
(08) 8947 7188
Email
admin-dims@dims.org.au
Address
30 Boulter Road, Berrimah NT
⚠️ IMPORTANT INFORMATION FOR REFERRERS (READ BEFORE COMPLETING)
To assist DIMS to make a timely and safe decision, this form must be fully completed.
DIMS will not accept referrals:
where risk is too high to safely manage
where key information is missing
where the client is not willing to engage
📅 Intake meetings occur Mondays at 1:30pm
Incomplete referrals may delay assessment or be returned.
How to complete and return this form
Complete all required fields in the interactive form.
When finished, select
Print / Save PDF
.
Save the completed form as a PDF on your device.
Email the saved PDF to
admin-dims@dims.org.au
.
Please ensure all relevant supporting documents are attached to your email where applicable.
SECTION 1: REFERRER DETAILS
Organisation Name:
Referrer Name & Position:
Phone: __________________________
Email: __________________________
I confirm I have obtained the client’s consent, or have lawful authority, to share their information with DIMS for referral, assessment and service delivery.
SECTION 3: SERVICE REQUEST (TICK ALL THAT APPLY)
What support are you seeking from DIMS?
Counselling and Psychological Support (1:1)
Healing and Behaviour Change Program
Readiness for Behaviour Change Program
Healthy Relationships Program
Therapeutic Radio Program (Custodial)
DIMS Central Brokerage Fund
DIMS Social Enterprise Casual Work Programs
SECTION 5: CURRENT BEHAVIOURS AND RISK (CRITICAL SECTION)
Provide specific detail (not general statements): What behaviours are occurring? Frequency and severity. Known triggers. Any escalation patterns.
SECTION 7: LEGAL STATUS / RESTRICTIONS
No current orders
Bail conditions
DVO
Parole / Corrections
Other: __________________________
Details (conditions relevant to program participation):
SECTION 9: ENGAGEMENT AND READINESS
How does the client currently present?
Willing to engage
Unsure
Resistant
Denies behaviour
Takes some accountability
Provide detail:
SECTION 11: ADDITIONAL INFORMATION
Anything else DIMS should be aware of:
SECTION 2: CLIENT DETAILS
Full Name:
Date of Birth: ______________________
Phone: __________________________
Address:
Aboriginal and/or Torres Strait Islander:
Select
Yes
No
SECTION 4: PURPOSE OF REFERRAL (REQUIRED)
What outcome are you seeking?
(e.g. behaviour change, risk reduction, court requirement, case plan)
SECTION 6: RISK SUMMARY (TICK + DETAIL)
Domestic and family violence
Physical violence
AOD (alcohol and other drugs)
Mental health concerns
Aggression / instability
Other: __________________________
Details:
SECTION 8: HIGH NEEDS / COMPLEXITY
Does the client have any of the following:
Significant mental health concerns
Cognitive impairment
High behavioural instability
History of disengagement from programs
Details:
SECTION 10: SUPPORTING INFORMATION
Please attach or summarise:
Risk assessment
Case plan
Court documents
Previous program reports
Summary (if not attached):
SECTION 12: DECLARATION
I confirm the information provided is accurate to the best of my knowledge.
Name: __________________________
Signature: _______________________
Date: __________________________
PAGE 2 – DIMS USE ONLY (INTAKE CHECKLIST)
✅ REFERRAL SCREENING CHECKLIST
Referral form complete
Risk information sufficient
Legal status confirmed
Supporting documents received
Engagement level identified
⚠️ INITIAL RISK SCREEN
Select
Low
Moderate
High
Not Suitable
Notes:
🧭 INTAKE OUTCOME
Select
Proceed to Intake Meeting
Request More Information
Not Accepted
📊 ASSESSMENT OUTCOME
Select
Suitable – Group Program
Suitable – 1:1 / Readiness
Not Suitable
🧾 FINAL DECISION
Accepted
Not Accepted
👥 INTAKE MEETING (MONDAY 1:30PM)
Client attended
Behaviour appropriate
Willing to engage
Code of Conduct explained
Reason:
Print / Save PDF
Reset Form
Reminder: Please select
Print / Save PDF
, then email the completed form to
admin-dims@dims.org.au
.