B-Heard REFERRAL FORM


Brimbank City Council offers a youth support service. This is a voluntary program that sees the delivery of up to

10 support sessions for young people aged 12 to 25 who live, work, study or socialise in Brimbank.

IMPORTANT INFORMATION

Referrers are required to contact a member of the Youth Support Team to discuss the needs of the young person, program eligibility, response times and any other questions prior to completing this referral form on 9249 4110.

Completed referral forms can be emailed to

ELIGIBILITY CRITERIA
The young person is aged between 12 – 25 years.
The young person lives, works,studies or socialises in the City of Brimbank.
The young person given consent to this referral being made.
The young person agreed to receive support from a BYS staff member.
You contacted a member of the Youth Support Team to discuss this referral first.
Yes No / Has the young person received support from BYS or another therapeutic program in the past? If yes, please provide further details

Date of Referral: / /

REFERRING AGENCY DETAILS
Name of worker:
Name of Agency/School:
Relationship to client:
Contact details / Correspondence Address:
Email:
Work number &/or Mobile:
Best time to call:
CLIENT DETAILS – all fields must be completed
Name:
Preferred Name:
Date of Birth: / Age: / Gender:
Pronoun: / He She They Other
Address:
Home Phone Number:
Mobile Phone Number:
Email Address:
Country of Birth: / Cultural identity:
Languages spoken: / Interpreter required: YES NO
Education/ Employment Status: / School TAFE University <15 not attending school
Employed Unemployed
Name of School/ Educational Institution:
Employment type: / N/A Full time Part time Casual
EMERGENCY CONTACT (Parent, Guardian or Adult over the age of 18 years)
Name: / Relationship to client:
Contact Details:
Is the young person’s parent/guardian aware of this referral? / YES NO
Has the young person given permission to contact them at home? / YES NO
To make an appointment is it best that the worker contacts: Client Referrer Parent

Presenting issues that the young person would like to seek support with: ***Please select no more than 3***

Alcohol & Other Drugs
Discrimination / Financial Issues
General Health / Managing Emotions (e.g. Anger)
Mental Health Difficulties
Education
Employment / Housing/Accommodation
Isolation / Relationship Issues
Self Esteem
Family Conflict
Family Violence / Legal Issues
Loss & Grief / Sexuality
Other:
Please provide further information in relation to these presenting issues and the impact on the young person:-
Presenting Issue 1
Presenting Issue 2
Presenting Issue 3
The role of your agency
How is your school/ agency
currently supporting the young person?
Over what length of time have you been supporting the young person?
What other services is the young person currently accessing support from?
Does the young person have a pre-existing mental health condition?
While working with the young person what strengths and interests have you identified?
Do you anticipate the young person experiencing any barriers in accessing support from our service? (e.g. transport to support sessions).
The role of BYS
What does the young person
hope to achieve from accessing
support at BYS?
Is there any other information that you would like to provide regarding this referral?
Brimbank City Council is committed to the protection of client privacy. The information collected through this form will only be used by Brimbank City Council for the purposes of the support program. It will not be provided to any other party or external agency without client consent.
Please nominate the type of consent that you have obtained from the young person for the referral to Brimbank City Council Youth Services.
VERBAL CONSENT / WRITTEN CONSENT
I have discussed the above referral and received verbal consent from the client for a referral to Brimbank City Council’s YouthSupport Service for the client’s information to be disseminated for the purposes of this referral. / I have discussed the referral to Brimbank City Council’s YouthSupport Service with my worker and have given consent for my information to be disseminated for the purposes of this referral.
Signature of referrer: / Client signature:
Name of referrer: / Worker signature:
Date: / / / / Date: / /
OFFICE USE ONLY:
 / Staff checklist
Contact made within a three day working period:
Screening completed with referrer:
Intake allocation at WA&P Meeting:
Intake Appointment - HEEADDSS and risk assessment completed:
Case Allocation at WA&PM:
Waiting List- holding support:
Allocated worker:
Ineligible Referral: