Step Out Form

Step Out Form
Email Address (hidden field for submission purpose)
Your email address will be used to confirm submission
Consent for referral provided by the client
- Client Details
- Personal Information
- First name
- Middle name
- Last name
- Date of birth
  
  DayMonthYear
  Date
- JAID
- CRN
- Identity and Culture
- Country of birth
- Cultural background
- Client identifies as First Nations
- Gender
- Communication details
- Contact number
- Contact email
  example@example.com
- Interpreter required
- Preferred language
- Contact address
- Post-release address known?
- Address
- Suburb
- Postal code
- Housing type
- Legal Details
- Offence History
- Current Offences
- Risks
- Primary Drug of choice
- Other substances of concern
- Safety concerns
- Other safety concern
- Release Details
- Prison location
- Prison release date
  
  DayMonthYear
- Today's Date
  
  DayMonthYear
- Calculate number of days
- Post-Release
- Client referred to ReConnect
- ReConnect Details
- Case worker allocated
- Reconnect Case Manager Information
- First name
- Last name
- Contact number
- Contact email
  example@example.com
- Consent Details
- Consent to share information with ReConnect
- Appointment
- Treatment Details
- Client treatment appointment preferences if a treatment is recommended by COATS
- Appointment Preferences
- Preferred Service Provider(s)
- Alternate option if preferred service provider is unavailable
- Other option
- Referrer Information
- Referrer Role
- Role
- Referring Person Information
- First name
- Last name
- ATC prison location
- Other worker organisation
- Please note, the referrer's primary email address is required to communicate the referral updates.
- Referrer contact number
- Referrer contact email
  example@example.com
- This form cannot be submitted as the client’s release date is either less than 20 days from today or more than 6 months in the future.
Should be Empty:

Step Out Form

Client Details

Personal Information

Identity and Culture

Communication details

Contact address

Legal Details

Risks

Release Details

Post-Release

ReConnect Details

Reconnect Case Manager Information

Consent Details

Appointment

Treatment Details

Appointment Preferences

Referrer Information

Referrer Role

Referring Person Information

Please note, the referrer's primary email address is required to communicate the referral updates.