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Referrer Details

Please provide your details as the person making this referral.

Referrer Full Name*

Relationship to Young Person*

Referrer Phone*

Referrer Email*

Name of Agency/Organisation

Referrer Address*

Street Address City State / Province / Region ZIP / Postal Code

Date of Referral*

How Long Have You Known the Young Person?*

Young Person's Details

Please provide details about the young person being referred.

Young Person's Full Name*

Preferred Name

Date of Birth*

Age*

Please enter a number from 12 to 25.

Cultural Identity

Gender Identity

Pronouns

Young Person's Address*

Street Address City State / Province / Region ZIP / Postal Code

Young Person's Email

Young Person's Mobile

Young Person's Preferred Method of Contact from Case Worker*

Are there any safety concerns when contacting young person by phone/text/email?*

Yes

No

Please describe the safety concerns*

Who does the young person currently live with?*

Young Person's Education/Employment Status*

Are there any other organisations/agencies currently involved with the young person?*

Yes

No

Please list the other organisations/agencies involved*

Parent/Guardian Details

Parent/Guardian Full Name*

Parent/Guardian Phone*

Parent/Guardian Address

Street Address City State / Province / Region ZIP / Postal Code

Is young person's parent/guardian aware of referral?*

Yes

No

Is young person's parent/guardian aware of the reasons for referral?*

Yes

No

Support Goals & Background

Please provide detailed information to help us understand the young person's situation and support needs.

What does the young person hope to achieve from case work support?*

What does referrer hope occurs for the young person by receiving case work support?*

Please provide a summary of the young person's situation, family and relevant background information*

Risk to self or others?*

Include self-harm / suicide ideation, substance abuse, aggression

Protective Factors

What is going well for young person currently?*

Is young person currently engaged in any recreational activities or has been in the past?*

What do you believe are the young person's strengths, skills, likes and dislikes?*

Any further information that young person/referrer would like for case manager to know?

Consents Required

The following consents are required to process this referral.

Consent by Young Person for Referral for Y Case Management Support

Young Person's Full Name (for consent)*

Date*

DD

MM

Year

Consent by Parent/Guardian for Referral for Y Case Management Support (School-Based Only)

This consent is required if the young person has selected to meet with a case worker in their school.

Parent/Guardian Full Name (for consent)*

Date*

DD

MM

Year

Verbal Consent (Referrer Use Only)

In cases where written consent from a parent/guardian was unobtainable, verbal consent from parent/guardian shall suffice.

Verbal Consent Obtained

I have discussed the referral with the young person's parent or guardian and they have consented to the referral being submitted.

Consent Obtained or Witnessed By*

Parent/Guardian Full Name (Verbal Consent)*

Date of Verbal Consent*

DD

MM

Year

How Would Young Person Like for the Referral to Proceed?

Please select the young person's preference for initial contact.

Preferred Initial Contact*

Please have case worker contact young person directly first

Please have case worker contact referrer directly first

Please have case worker contact parent/guardian directly first

Case Management Referral Form

Referrer Details

Young Person's Details

Parent/Guardian Details

Emergency Contact Details

Young Person's Preferred Location of Case Management Sessions

School-Based Session Details

Support Goals & Background

Protective Factors

Consents Required

Verbal Consent (Referrer Use Only)

How Would Young Person Like for the Referral to Proceed?