PHaMs (Personal Helpers and Mentors) Application Form

Name of Person Referred
Date of Referral
The person being referred must meet the following eligibility criteria? Requires support with mental health issues. No formal diagnosis required May be homeless or live in insecure accommodation Are aged 16 and over Connection or reside in the Greater Dandenong Region (3171-3175) Have the desire and are agreeable to actively participating in the program to make positive changes
Name of Person Making Referral
Relationship to the Person Referred
Name of Organisation (if applicable)
Contact Phone No
Email

Source of Referral for the Applicant