Compeer Friendship Program (NSW) Application Guidelines

What is Compeer?
Compeer is a friendship program for adults who are living with a diagnosed mental illness. Our aim is to
promote social inclusion within the community, while reducing stigma surrounding mental health concerns.
The program is ideal for those who are ready to engage in a friendship with a volunteer from the community.

Who is the Compeer Program suitable for?

The Compeer program is suitable for adults in the community who experience mental illness and have
identified they would like social support to assist in their recovery.

Where are Compeer offices located?

CENTRAL COAST SYDNEY HUNTER REGION MACARTHUR/ ILLAWARRA/
PO BOX 148 PO BOX 5 PO BOX 817 WINGECARRIBEE SHOALHAVEN
Wyong NSW 2259 Petersham NSW 2049 Hamilton NSW 2303 24 Iolanthe St PO BOX 99
M: 0436 111 102 P: 9568 0295 P: 4032 3582 Campbelltown 2560 Warrawong NSW 2502
E: compeercentralcoast E: compeer@vinnies.org E: compeernewcastle P: 4627 9180 P: 4276 4229
@vinnies.org.au .au @vinnies.org.au E: compeermacarthur E: compeer@svdpwong
@svdpwgong.org.au .org.au

Who can make an application to Compeer?

The applicant, together with their health professional (e.g. GP, psychologist, OT, support worker) can make
an application. Please note: this application is only active for a specific time period; therefore you will need to
submit a new application after expiration. For more information and time frames, contact your nearest
Compeer office on the details listed above.

Eligibility Checklist:
1. The applicant is 18 years of age or older
2. The applicant is seeing a health professional (see definition above) for regular support
3. The applicant is living with a diagnosed mental illness
4. The applicant is ready to engage in a one-on-one friendship to assist their recovery

Suitability Assessment
Compeer promotes equal and sustainable friendships. For this reason, there are certain circumstances that
may affect this application. These include:

- Personality / suspected personality disorder

- Intellectual disability
- Drug / alcohol dependence
- Acquired brain injury or neurological condition
- Subject to an AVO
- On a community treatment order (CTO)

If any of these conditions apply, please contact your nearest Compeer office prior to completing the
application. Each application will be assessed on an individual basis.
*please note that additional factors may be identified in the application process which may lead to Compeer being unable to accept an application.

Compeer Application Form November 2016 Page 1 of 8

 Part I
Part I can be filled out by the applicant (with the health professionals assistance if required). Alternatively,
the health professional can complete if preferred. Please print clearly.

SECTION A: Applicant details

1. APPLICANT NAME: _________________________________________ D.O.B: ______/______/__________

ADDRESS: ___________________________________________________ POSTCODE: _________________

MOBILE: __________________________________________________ _____ LANDLINE: __________________

EMAIL: ______________________________________________________ GENDER: ___________________

PREFERRED CONTACT METHOD: ________________________________ SMOKER: Yes No

COUNTRY OF BIRTH: ________________________ LANGUAGES SPOKEN: ___________________________

CULTURAL BACKGROUND (optional): ___________________________________________________________

2. NEXT OF KIN / EMERGENCY CONTACT NAME: ________________________________________________

RELATIONSHIP: _____________________________ CONTACT NUMBER: _____________________________

3. LIVING SITUATION: ______________________________________________________________________

SECTION B: For matching purposes

4. WHAT DO YOU HOPE TO GET OUT OF THE COMPEER PROGRAM?
__________________________________________________________________________________________
5. WHAT WOULD YOU LIKE THE VOLUNTEER TO KNOW ABOUT YOU?
__________________________________________________________________________________________

__________________________________________________________________________________________

6. PLEASE SELECT YOUR INTERESTS AND HOBBIES (you can select as many as you like):

TV / Movies Sports Arts / Culture Bushwalking Nature / Outdoors

Community Travel Gardening Reading Cooking / Food

Spirituality / Craft / Politics / History / Beach / Lake

Religion Visual art Current affairs Geography (Swimming / surfing)
Other: ______________________________________________________________________________________

7. IS IT IMPORTANT TO YOU TO HAVE A VOLUNTEER OF A SPECIFIC AGE, LANGUAGE, RELIGION,

CULTURAL BACKGROUND OR SEXUAL ORIENTATION (same gender matching only)?
No Yes (please specify): ____________________________________________________________

8. HOW FAR ARE YOU WILLING TO TRAVEL TO MEET A COMPEER VOLUNTEER (one-way)?
15 minutes 30 minutes 45 minutes 1 hour
Comments (e.g. areas / locations): ______________________________________________________

Compeer Application Form November 2016 Page 2 of 8

9. PLEASE SPECIFY THE MAXIMUM AGE RANGE YOU WOULD BE COMFORTABLE BEING MATCHED WITH:
__________ - __________ Comments: _______________________________________________

10. WHEN WOULD YOU BE ABLE TO MEET WITH A COMPEER VOLUNTEER?

Monday Times:

Tuesday Times:

Wednesday Times:

Thursday Times:

Friday Times:

Saturday Times:

Sunday Times:

11. CAN YOU BE FLEXIBLE WITH THESE TIMES AND DAYS?:

Yes No Comment: ___________________________________________________

12. HOW OFTEN WOULD YOU BE AVAILABLE ON THE DAYS INDICATED (4 hours per month)?
Weekly Fortnightly Comment: ___________________________________________________

13. WOULD YOU LIKE YOUR HEALTH PROFESSIONAL / SUPPORT WORKER TO BE PRESENT WHEN YOU
FIRST MEET THE VOLUNTEER? (the meeting is facilitated by Compeer):
Yes, it is important to me that my health professional be present at the initial meeting
I would prefer if they attend, but it is not essential
It doesnt matter to me either way if my health professional is present or not
I would prefer to attend without my health professional being present

--------------------------------------------- END PART I ---------------------------------------------

Compeer Application Form November 2016 Page 3 of 8

 Part II
To be completed by the health professional supporting the application. Additional information may be required
in case of emergency.

SECTION C: Health Professional Details

In the event the applicant is discharged from your service, please advise Compeer immediately

14. NAME OF HEALTH PROFESSIONAL SUBMITTING THE APPLICATION: _______________________________

AGENCY / PRACTICE NAME: _______________________________ PHONE: ____________________________

ADDRESS: _________________________________________________________________________________

EMAIL: _____________________________________________ _____ BEST TIME FOR CONTACT: ____________

15. CURRENT INVOLVEMENT:

a.) How long have you worked with the applicant? __________________________________________________

b.) How often do you see the applicant? __________________________________________________________

c.) Does the applicant have difficulty keeping appointments? No Yes Comment: _______________

d.) Is the applicant easily contactable by phone? No Yes Comment: ___________________________

e.) Does the applicant have a secondary health professional?: No (go to section D) Yes

- Name of secondary health professional: ____________________________________________________

- Phone: _________________________ Email: ___________________________________________

SECTION D: Mental health history

Please provide as much detail as possible and attach additional documentation (if applicable)

16. DIAGNOSIS: ________________________________________________________________________________

17. SYMPTOMS: a) Current: _________________________________________________________________

b) When applicant is unwell: ____________________________________________________

18. MENTAL HEALTH HISTORY (i.e. when diagnosed, circumstances, hospital admissions, fluctuations)

_______________________________________________________________________________________________

_______________________________________________________________________________________________

19. PLEASE ADVISE OF ANY SIGNIFICANT TRAUMA-RELATED FACTORS COMPEER MIGHT NEED TO BE
MINDFUL OF (if relevant):

_______________________________________________________________________________________________

20. DOES THE APPLICANT TAKE MEDICATION TO MANAGE THEIR MENTAL ILLNESS?:

No Yes (please specify any relevant side effects) __________________________________________

21. SERVICES CURRENTLY INVOLVED IN THE APPLICANTS SUPPORT AND RECOVERY:

_______________________________________________________________________________________________

Compeer Application Form November 2016 Page 4 of 8

 SECTION E: Risk Assessment
22. SUICIDALITY & SELF-HARM
a.) What is the applicants current suicide risk (over the past six months)?

Nil Low Medium High

b.) Is the applicant currently experiencing suicide ideation? Yes No

c.) Does the applicant have a history of suicidal behaviour? Yes No
d.) Does the applicant engage in self-ham? Yes No
e.) Please provide relevant detail regarding suicidality and self-harm (including history, management and protective
factors) __________________________________________________________________________________

_______________________________________________________________________________________

23. RISK TO / FROM OTHERS

a.) What is the applicants current risk to others (over the past six months)?
Nil Low Medium High
b.) What is the applicants current risk from others (over the past six months)?
Nil Low Medium High
c.) Is the applicant currently experiencing thoughts of harming others? Yes No
d.) Have there ever been incidents of verbal or physical aggression? Yes No
e.) Does the applicant have a criminal record? Yes No
f.) Please provide relevant detail regarding risk to others (including history, management and protective factors)
_______________________________________________________________________________________

_______________________________________________________________________________________
g.) Is the applicant experiencing any violent or threatening behaviour from others? Yes No
- Is this likely to impact on the volunteer and / or outings? Yes No
- Please provide relevant detail regarding threat from others (including history, management and protective
factors) ______________________________________________________________________________

____________________________________________________________________________________

24. ALCOHOL OR OTHER DRUG USE

a.) Does the applicant have a history of excessive alcohol or drug use? Yes No

- Please provide relevant detail: ____________________________________________________________

____________________________________________________________________________________

- How is this issue currently being addressed? ________________________________________________

____________________________________________________________________________________

25. DOES THE APPLICANT HAVE OTHER ADDICTIVE / COMPULSIVE BEHAVIOURS THAT MAY EFFECT SOCIAL
FUNCTIONING WITHIN COMPEER (e.g. gambling, shopping, OCD behaviours)?
____________________________________________________________________________________________

Compeer Application Form November 2016 Page 5 of 8

 SECTION F: Social Functioning
26. PLEASE DESCRIBE THE APPLICANTS PERSONALITY AND STRENGTHS:

____________________________________________________________________________________________

____________________________________________________________________________________________

27. PLEASE DESCRIBE THE APPLICANTS INTERPERSONAL SKILLS:

____________________________________________________________________________________________

____________________________________________________________________________________________

28. PLEASE IDENTIFY ANY CONCERNS WITH SELF-CARE:

____________________________________________________________________________________________

29. PLEASE IDENTIFY ANY STRATEGIES THAT MAY ASSIST THE VOLUNTEER IN ESTABLISHING RAPPORT:

____________________________________________________________________________________________

SECTION G: General Health

30. DOES THE APPLICANT HAVE ANY PHYSICAL OR INTELLECTUAL DISABILITY OR MEDICAL CONDITIONS?
No (go to section H) Yes (please comment) _________________________________________________

- How do they manage their condition? ___________________________________________________________

- How might it impact the Compeer friendship? ____________________________________________________

_________________________________________________________________________________________

SECTION H: Acknowledgement and Agreement

FOR THE REFERRING HEALTH PROFESSIONAL / SUPPORT WORKER
a.) I agree that the information provided is current and accurate to the best of my knowledge. If the information
changes, I agree to contact Compeer and update the information
b.) I agree to support the applicant in the Compeer program for the duration of their participation. I understand and
agree to:
- Be available to Compeer staff regarding issues concerning the applicant
- Be available to attend an initial Compeer meeting, if support is identified
- Contact Compeer if the applicant discharges from my service, or has a change in wellness

______________________________ ______________________________ __________________

Name of health professional Signature Date

FOR THE APPLICANT

a.) I agree to participate in the Compeer program
b.) I agree that the information provided is current and accurate to the best of my knowledge. If the information
changes, I agree to contact Compeer and update the information
______________________________ ______________________________ __________________
Name of applicant Signature Date
*Please continue through to the next page to sign the consent form

Compeer Application Form November 2016 Page 6 of 8

 St Vincent de Paul Society NSW
ABN: 91 161 127 340

Compeer Program
PO Box 5
Petersham NSW 2049
Telephone: (02) 9568 0232
Facsimile: (02) 9564 2097
compeer@vinnies.org.au
www.vinnies.org.au
Donation Hotline: 13 18 12
COMPEER FRIEND CONSENT FORM
Compeer within the St Vincent de Paul Society NSW, requires your consent to collect, use and disclose personal
information [per the Federal Privacy Act 1988 (as amended)] in order to assess suitability for the program, and / or for
the purposes of providing a Compeer friendship.

Compeer collects personal information such as your:

Name
Date & country of birth
Contact / emergency contact details
Medical & psychological history
Social history

Without this information Compeer is unable to provide an appropriate service.

Compeer will keep your personal information secure and will not give it to other people without your consent, unless it is
an emergency and / or as required by law (e.g. where your safety or the safety of others is at risk).
You can access your information by contacting Compeer and making an appointment.
The information provided may be disclosed to the following parties for the purposes of assessing suitability for the
program, matching with an appropriate Compeer volunteer, supporting the Compeer friendship, and addressing any
difficulties that may arise during the Compeer friendship:
Compeer & St Vincent de Paul Society NSW staff (as required)
A potential Compeer volunteer (in a limited, de-identified way) and / or the volunteer you are matched with
The health professional supporting you in your Compeer friendship
Other health professionals & mental health services involved in your care, (as required)
The person you have designated as the person responsible for giving and accessing your information (if
applicable)

If you have a carer, family member or other contact that you give us permission to disclose your personal information to,
and discuss your Compeer participation with, please provide details below:
Name of contact: __________________________ Relationship: _______________________________________

If you are unclear about or disagree with any of the above disclosures, please contact Compeer.

If you have any limitations to disclosures, please note them here:

_______________________________________________________________________________________________

This authority is valid for 2 years from the date of signing. You are able to withdraw your consent at any time by
contacting Compeer or completing the withdrawal of consent on the following page. For further information about your
privacy, please contact Compeer.

YOUR CONSENT:
I have read and understood the above and consent to the intended uses and disclosures of the personal information
that the Compeer Program holds.

______________________________ ______________________________ __________________

Name of applicant Signature Date
______________________________ ______________________________ __________________
Name of witness Signature Date

Compeer Application Form November 2016 Page 7 of 8

 WITHDRAWAL OF CONSENT

I___________________________ (name of applicant) withdraw my consent to share information with the following

individuals/organisations. Please specify:

_______________________________________________________________________________________________

_______________________________________________________________________________________________

*Please note that withdrawal of consent from particular parties may mean that Compeer will be unable to
provide an appropriate service. Please contact Compeer for more information.

______________________________ ______________________________ __________________

Name of applicant Signature Date

Compeer Application Form November 2016 Page 8 of 8