Moving FWDProgram– Referral Form

Referral Agency/School Details

Date of Referral: ______Agency/School Referring: ______

(Please Note: If a school referral, please obtain a name and signature from either the Vice Principal or the Principal).

Vice Principal  Principal  Name:______Signature:______

Referee contact details:

Name: ______Phone: ______

Email: ______

Relationship to young person (eg: SWC, case worker, relative): ______

PLEASE NOTE: It is a pre-requisite for Moving FWD participants to have a case manager. Where a referral is made to Moving FWD without this, the young person will be linked to Council’s Outreach Program to assist further, prior to their participation on Moving FWD.

Young Persons Details

Name:______

Gender:______Age:______years D.O.B. ____/____/____

Cultural Identity:______Aboriginal/Torres Strait Islander 

Is an interpreter required? Yes No Specify language:

Home Address:______

______

Home Phone:______Young Person’sMobile Phone:______

Email: ______

Residential Status:

 With parent/guardian  Homeless  Other: ______

Emergency contact person: ______

Mobile Phone: ______Relationship: ______

Current Social Supports: family, guardians, siblings and significant others

______

______

Current Welfare Supports: is the young person currently linked with any support services or workers?

NameOrganisationContact Number

______

______

Has the young person currently / previously had DHS involvement?: Yes No

If yes, please detail: Child Protection Youth JusticeDisability

______

______

Referral Information

Physical Health: does the young person have any physical and/or medical health issues? Yes No

Condition: Please specify e.g. ASD, intellectual disability, epilepsy, allergies, hearing/sight impairments, ABI etc. / Diagnosed /
Undiagnosed
(D / U) / How the condition presents/ management of/ special requirements/ treatment/ medication etc.

Mental Health: does the young person have any mental health issues? Yes No

Condition: Please specify e.g. ADHD, ODD, anger management, depression, anxiety, PTSD/grief, eating disorder, poor communication/social skills etc. / Diagnosed /
Undiagnosed
(D / U) / How the condition presents/ management of/ special requirements/ treatment/ medication etc.

Is the young person currently/previously experiencing suicidal ideation/self-harming behaviours?

Please detail history below: Yes No

______

______

______

Alcohol & Other Drugs: does/has the young person have/had any AOD issues? Yes No

Type: Please specify e.g.alcohol, binge drinking, ice, methamphetamines,cannabis etc. / Current Use/ Previous Use
( C / P ) / Please specify effects, rate of use (often/ occasional), last date of use, current/ previous treatment/counselling etc.

Legal History: does/has the young person have/had any legal issues? Yes No 

Type: Please specify e.g. Fines, debts, criminal offences (detail) etc. / Current / Previous
( C / P ) / Please specify details, e.g. pending legal charges, court dates, sentences, restrictions etc

Education and Training: is the young person currently attending school/training? Yes No 

Current/ last school/college attended: ______

Completed Year level:______Left school when: ______

Contact details: ______

Employment: is the young person currently employed? Yes No 

Details: ______

Is the young person currently under a traineeship/apprenticeship? Yes No 

Details:______

Does the young person have a Job Service Provider? Yes No 

Details:______

Does the young person have issues with literacy/numeracy/reading? Yes No 

What kind of work/study would the young person like to undertake in the future?

______

______

Does the young person engage in any activities/hobbies regularly? Yes No

Details: ______

Please describe any other issues/reasons for referral that Program staff may need to be aware of:

______

______

______

______

______

______

Participant Consent

All referrals to Moving FWD/OutreachMUST BE DISCUSSED with the young person. Where possible, also discuss with the young person’s family/support network.

A worker from Hume City Council Youth Counselling and Support Unit will contact the young person for further information and to organise an initial meeting.

Where a referral is made for a young person without a case manager, the referral will be provided to Council’s Outreach program for follow up prior to their participation in Moving Forward.

Please indicate below that the young person has agreed & is aware their details have been passed on to Hume City Council Youth Services.

 Yes I have discussed this referral with the young person

 Yes I discussed this referral with the young person’s parent/guardian

 No I have not discussed this referral with the young person’s parent/guardian

Worker Signature:______Date:

RETURN TO: (Please note that referrals via email are preferred)

Moving FWD Program Officers
Hume City Council Youth Services
PO Box 119
Dallas 3047 / Email:

Tel: 9205 2556

Office use only

First contact date:______Worker: ______

File Number: ______

 Yes I have consent to seek further information

Referral appropriate for Outreach? Yes No

Follow up action:

Referral appropriate for Moving FWD? Yes No

Follow up action: ______

Comments:

______

______

______

Moving FWD is funded byHume City Council Youth Services.

Privacy Statement

Council collects personal and health information to provide you with Counselling and Support services. Council complies with the Privacy and Data Protection Act 2014 and the Health Records Act 2001 when collecting and using this information. The information may be shared with Commonwealth and State Government service providers as considered appropriate but will not otherwise be released except as required by law. You may access this personal and health information by contacting Council on 92052200.

C:\Users\virginiaw\AppData\Local\Microsoft\Windows\Temporary Internet Files\Content.Outlook\UF57EKZ9\REFERRAL DRAFT.doc