Updated April 2014

SouthWest youth servicesCOUNSELLINGreferral form:

167-169 Queen Street Campbelltown 2560 NSW

Tel: (02) 4621 7416 direct / 4621 7400 receptionFax: (02) 4628 5971

Client Details

Surname: / Given Name(s)
Gender: / School YP attends (if applicable)
Date of birth: / (Must be 12-24 or EIPP client)
Age: / Phone:
Referrers name / Relationship to Young person:
Exit date if applicable:

Medical Information

Significant medical condition/s
Medication:
Paediatrician:
Diagnoses:

Emergency contact

1. Legal guardian
Name / Address / Phone
2. If unavailable contact
Name / Address / Phone

Personal details

Country of birth / Preferred Language
Aboriginal Torres Strait Islander / Yes / No
From a non-English speaking background / Yes / No
Any disabilities? (If yes, please specify)

PLEASE COMPLETE PAGE 2

OTHER HEALTH PROFESSIONALS INVOLVED IN CARE:
Counsellor
Psychiatrist/Clinical Psychologist
Case Manager (If not Mission Australia)
Doctor (General Practitioner)
 Juvenile Justice
Other, please specify:

BASIC Background information:

Related Behaviours, family changes, history or currently suicidal or self-injuring behaviour?
Triggering events? Harm to others? Managing temper/anger?

Presenting Issues:

Please provide just a brief summary of presenting issues or reasons for the referralonly if the young person is willing to disclose (e.g.grief, trauma, loss, anxiety, relationship breakdown etc.)

The following questions are necessary to share information required for WHS policies.

  • Within the last 2 weeks have there been safety concerns from this person to…?

SelfNO/YES | To OthersNO/YES | From OthersNO/YES

  • If yes, what is being done to manage those risks? ______
  • Suicidal thoughts or plans require an immediate response. I recommend calling Lifeline 131114, or Suicide Callback Service 1300 659 467, or Mental Health COMHET team 1800 011 511. Clients may also be accompanied directly to Browne St Community Mental Health or Headspace. If there is any doubt about accessing a professional service safely then call Ambulance 000.
  • Have there ever been threats to staff safety? NO/YES

When? ______

  • Has the identified client assaulted any other clients in your school or local agency?

NO/YES

When? ______

  • For Home Visits only: Any hazards in home environment?DON’T KNOW / NO / YES

Any current AVOs, ADVOs, PVOs? NO/YES

(Please note that Children and Young Persons (Care and Protection) Act 1998 Chapter 16A permits interagency disclosure when required to address risks of harm to children)

I confirm to the best of my knowledge that the above information is correct.

Signed (Worker): Date:

I understand that personal information about me held by this referring agency may be supplied to the Youth Counsellor for the purpose of providing services to me. I also understand that personal information about me that is collected by any staff at Mission Australia may be supplied to the Youth Counsellor. Your privacy in counselling will be discussed in the first meeting. Please discuss any concerns you may have about these arrangements.

Client (Recommended):Date:

1