REFERRAL FORM CLIENT LABEL
Strictly Confidential
Please complete this form and send to the Referral Manager, who will forward the referral to the Referral Review Committee
PARENT/CAREGIVER AGREEMENT TO REFERRAL
Name: Date:
Original Date of Referral:
REFERRED YOUNG PERSON
Surname: Other Names:
Is the child known by another name?
Date of Birth: Age: Gender: M/F
Aboriginal/Non-aboriginal/CaLD Country of Birth:
Address:
Home Phone: E-mail:
Interpreter Required: Yes/No Language:
Mother’s Surname: First name:
Mother’s Work Phone: Mother’s Mobile:
Father’s Surname: First name:
Father’s Work Phone: Father’s Mobile:
Legal Guardian: First name:
Relationship to young person:
REFERRAL DETAILS
MST Referral Manager:
Agency:
Referrer:
Position:
Agency (if different from above):
Address:
Phone: Mobile:
E-mail Address:
Length of time this agency has been involved with the young person:
Date of last contact with this young person:
REASONS FOR REFERRAL
1 Drug or alcohol abuse/dependence:
FACTOR
/LEVEL OF ENGAGEMENT
Early Signs of Disengagement / Extremely DisengagedSubstance Use / 1
Experimentation. / 2
More regular using. / 3
Drug usage interfering with school (may come to school intoxicated). / 4
Substance abuse key coping strategy. / 5
Substance abuse substantially impeding interventions.
Comment:
2 Domestic violence/aggression involving the young person:
FACTOR
/LEVEL OF ENGAGEMENT
Early Signs of Disengagement / Extremely DisengagedVerbal/Physical Aggression / 1
Verbal aggression occurring at least twice a week. / 2
Verbal aggression occurring 4 times a week. / 3
Verbal aggression occurring daily. / 4
Verbal aggression occurring daily and physical occurring at least twice a week. / 5
Verbal and physical aggression occurring on a daily or near daily occurrence.
Comment:
3 Out of home placements/risk of out of home placement:
FACTOR
/LEVEL OF ENGAGEMENT
Early Signs of Disengagement / Extremely DisengagedOut of home placement / 1
Never had an out of home placement. / 2
Ongoing threats of out of home placement. / 3
Had one previous episode of out of home placement. / 4
Had more than one occasion of being out of the home. / 5
Currently young person is living out of the home.
Comment:
4 Juvenile offending:
FACTOR
/LEVEL OF ENGAGEMENT
Early Signs of Disengagement / Extremely DisengagedJustice/Police Involvement / 1 / 2
Possible juvenile cautions. / 3
Student likely to be known to Police. Possibly committed minor offences / juvenile cautions / first offences. / 4
Likely to have offended. Possible increase in severity / frequency of offending behaviour. / 5
Possible periods of detention / incarceration.
Comment:
5 Associated Issues:
FACTOR
/LEVEL OF ENGAGEMENT
Early Signs of Disengagement / Extremely DisengagedAssociated Issues / 1
Higher than normal family conflict (with teenagers). / 2
Conflict substantially impacting on well being of family unit. / 3
Parents not coping – expressing that they may kick their child out. / 4
Student at strong risk of homelessness. / 5
Student cannot be located. Homeless.
Comment:
6 School attendance/behaviour/suspensions/family factors:
FACTORS
/LEVEL OF ENGAGEMENT
Early Signs of Disengagement / Extremely DisengagedAttendance / 1
Occasional absences
~75-80% attendance
(~1 day/week). / 2
Can be absent 1-3 days/week on a term average. / 3
Sporadic attendance. Can be away for up to 3-4 consecutive days in a 2-week timeframe. / 4
Student attending less than 50% of the time. / 5
Student not attending/enrolled at school.
Formally excluded from school.
Whereabouts unknown.
Behaviour / 1
Disruptive in some classes, eg., attention seeking, provocative / inappropriate language / comments. / 2
Disruptive behaviour that impacts on other students’ learning (throwing things, pushing, confrontation). / 3
Significant disruption in most classes. / 4
Perceived risk of behaviour threatening the safety of self, other students or staff. / 5
Behaviour (physical/ verbal) that has impacted on the safety of staff or students (eg., physical assault, threats of serious harm).
Frequency of above School Behaviour / 1
Rarely. / 2
Several times each term. / 3
Approximately weekly. / 4
Several days in each week. / 5
Almost every day.
Suspensions / 1
1-2 suspensions a term. Student doesn’t want to be suspended. / 2
2-3 suspensions a term. Student likes being in some classes (subject / social reasons). / 3
4-5 suspensions a term. Gaps in suspension. Suspensions increasing in length and category severity. / 4
Student being suspended within a few days of returning to school. Schools only response to behaviour. Exclusion considered. / 5
Recommended for Exclusion Order made by school or Exclusion imminent without significant intervention.
Family Factors / 1
Family concerned but limited contact between school and home. Home concerned about suspensions /attendance. / 2
School contact home more frequently (1-2 times a week). Home concerned about increasing suspensions / attendance. / 3
Home feels that school-suspending child ineffectual. Parents may attend school meetings but high level of frustration or anger. Parents express that they can’t get their child to school (or get them to appointments, etc.). / 4
Home difficult to contact to notify of suspension. Parents will not attend meetings with school. / 5
Parents actively avoid communication with school. Family issues significantly impede interventions.
Comments:
7 Mental health issues/diagnoses, including in-patients admissions:
8 Threat to harm self or others/actual harm to self or others (Note if harm to self/others or threats to self/others in previous 12 months, please attach comprehensive details regarding the incidents to help ascertain future risk):
9 Other relevant information:
CURRENT AGENCY INVOLVEMENT
1 Name:
Address:
Phone: Contact:
2 Name:
Address:
Phone: Contact:
3 Name:
Address:
Phone: Contact:
PREVIOUS AGENCY INVOLVEMENT
1
2
3
4
HOME SITUATION
With whom does the young person reside?
Where has the young person lived for most of the last 6 months?
Current family situation (genogram; stability of family; nuclear/blended/single parent family):
What is the primary language of the caregiver? .
What is the primary language of the young person? .
SCHOOL SITUATION
Enrolled School: ………………..…………………………………………………………………..
Attendance Record: ……………………………………………………………………………………..
Address:
Phone: Contact:
(eg. School psychologist, RAP team, Year Coordinator, SPER staff)
Comments re school achievement/ learning difficulties:
MEDICAL INFORMATION
Medications:
Prescribing Doctor:
Address:
Phone: E-mail:
Please attach signed Release of Information Form and copies of previous assessments on the young person.
REFERRAL CHECKLIST
Have you?
§ Obtained signed consent? Yes/No
§ Given the information sheet and MST brochure
to the caregiver? Yes/No
§ Explained to the family that this is a Referral, and
that MST Services will not follow automatically? Yes/No
§ Explained to the family that MST is an intensive,
home-based service? Yes/No
§ Enclosed supporting reports/information? Yes/No
Note to Referral Managers:
Although MST Clinicians endeavour to engage with the client family to achieve mutually desired outcomes, sometimes this is unsuccessful and the case must be terminated. Upon case closure and/or case completion, the Referrer is contacted by the MST Clinician with the case Discharge Summary, and alternative family supports may need to be organised by the Referrer.
Sending of Referral Forms:
REFERRALS CAN BE POSTED OR FAXED THROUGH TO THE MST PROGRAM MANAGEMENT OFFICE.
MST Postal Address:
MST Program
Fremantle Hospital
Alma Street Centre, W Block Level 6
PO Box 480
Fremantle WA 6959
MST Fax: 9431 3780 MST Phone: 9431 3787
CONSENT FOR REFERRAL
TO THE
MULTISYSTEMIC THERAPY PROGRAMME
I …………………………………………………………….. parent / guardian of
………………………………………………………………. (child’s name)
give my consent for this referral to the Multisystemic Therapy Program.
It has been explained that this is a Consent for Referral only, and that Multisystemic Therapy services may not necessarily be provided.
Signature:
Date:
Updated 16.06.08 Page 8 MST 110