Referral for Transitional Housing for High-Risk Youth
I. Customer’s Information
Name : (Chinese中文) (English英文)
HKID No. Tel. No.
Address :
Corresponding Address :
Tel. No.
Date of birth :YMD Place of Birth :
School / Employer : Tel. No.
Name of Parent(s)/Guidance : Tel. / Pager No.
II. Reasons of running away from Home/Reasons of not living at Home :
III. Case Summary
(1) Family Background & Relationship
(2)Customer’s performance at school / work
(3)Customer’s emotional & behavioral characteristics(4) Worker’s Intervention
(5) Brief Case Development
(6) Medical History
Yes / No / Unknown
1. / Is thecustomer(C) or any family member(F) currently underobservation or taking any treatment or medication? / C / C / C
F / F / F
2. / Has the customer or any family member had any operation, treatment, hospital care or medical examination before? / C / C / C
F / F / F
3. / Has thecustomer or any family member had any form ofsexually transmitted disease or is there anything about his/herlife style which could expose him/her to the risks of AIDS? / C / C / C
F / F / F
4. / Has the customer or any family member had the tendency ofsuicide or had attempted/committed suicide before? / C / C / C
F / F / F
5. / Is thecustomer or any family member suffering from any health(physical/psychological/psychiatric) problem? / C / C / C
F / F / F
6(a). / Is the customer or any family member having any drugs abuse behavior? / C / C / C
F / F / F
6(b). / Is the customer or any family member now still abusing drugs? / C / C / C
F / F / F
7. / Is thecustomer or any family member have any triad society background? / C / C / C
F / F / F
Please provide details of each question answered “Yes”.
Question No. / Name of Person treated / Details of Ailment / Duration Dates / Degree of Recovery / Name & Telephone of attending doctor(7) Recommended Length of Stay in Youth Outreach
(8) Intervention Plan Suggested for Youth Outreach
(9) Remarks
IV. Referring Agency
Name of Agency: Countersigned by Supervisor:
Name of Centre: Name:
Responsible Social Worker: Title:
Tel / Pager No.:Date: YM D
Signature:
Date: Y M D
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For Official Use Only
Date of entry : Y M D Date of check-out : Y M D
Staff :
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