Youth Insearch Referral Form
Referrer details
REFERRAL SOURCE
Referral source
Individual
Organisation
What category best fits as the referring organisation?
Referring organisation
Community services
Youth and Family Services
Mental health services
Disability services
Health services
Education system
Employment services
Housing services
Housing services - Out of Home Care
Legal services
Legal services - Work Development Order (WDO)
Other
Internal referral by Youth Insearch
What category best fits as the referring organisation?
Referring individual
Self referral
Family member
Friend
Doctor / GP
Other
What category best fits as the referring organisation?
REFERRER DECLARATION
Referrer declaration
I acknowledge and confirm the following referral conditions:
The young person referred (and/or guardian if young person is under 18) is aware of an understands the referral booking being made to Youth Insearch services.
The information I have provided
in this referral is accurate and complete to the best of my knowledge.
I have provided all relevant information that may assist Youth Insearch in delivering appropriate services to the young person referred.
REFERRER INFORMATION
Referrer First Name
Referrer Last Name
Referrer Job Title
REFERRER CONTACT DETAILS
Referrer Email
Preferred phone
Home
Work
Mobile
Phone (Home)
Phone (Work)
Phone (Mobile)
Please enter at least one phone number
REFERRER ADDRESS
If you have problems with the Google autocomplete, please select any similar address then type over the top of it with the correct details in the relevant boxes. You can also try googling the address first to ensure you have the correct suburb &/or postcode (e.g "Gladstone" or is it really "West Gladstone")
Street Address
Start typing the
street number
only (u
ses Google autocomplete)
.
If there is a unit or villa number, add it in the field below
Unit or Villa Number (only)
City/Suburb - *autocompletes*
State - *autocompletes*
Postcode - *autocompletes*
CLIENT DETAILS
YOUNG PERSONS INFORMATION
First Name
Last Name
Preferred Name
Pronouns
Please select...
she/her/hers
she/they
he/him/his
he/they
they/them/theirs
other/ask me
Date of Birth
Is the young person under 18 years of age?
Yes
No
YOUNG PERSONS CONTACT DETAILS
Email
If young person does not have email, enter referrers email
x
Phone (Home)
Phone (Mobile)
Phone (Work)
Preferred Phone
Mobile
Home
Work
Please enter at least one phone number
YOUNG PERSONS HOME ADDRESS
If you have problems with the Google autocomplete, please select any address then type over the top of it with the correct details in the relevant boxes
. You can also try googling the address first to ensure you have the correct suburb &/or postcode (e.g "Gladstone" or is it really "West Gladstone")
Street Address
Start typing the
street number
only (u
ses Google autocomplete)
.
If there is a unit or villa number, add it in the field below
Unit or Villa Number (only)
State - *autocompletes*
City/Suburb - *autocompletes*
Postcode - *autocompletes*
YOUNG PERSONS IDENTITY AND CULTURE
What is the young persons
gender
Please select...
Male
Female
Non Identified
Gender assigned at birth
What is the young persons
gender identity
?
Gender young person identifies with
Does the young person identify as part of the
LGBTIQA+ community
?
Yes
No
Prefer not to say
What is the young persons
main language spoken at home
?
What is the young persons
country of birth
?
Does the young person identify as
Aboriginal and/or Torres Strait Islander
?
No
Yes, Aboriginal
Yes, Torres Strait Islander
Yes, both Aboriginal and Torres Strait Islander
Prefer not to say
What
school
does the young person attend?
CLIENT WELLBEING
YOUNG PERSONS WELLBEING
Does the young person have a
disability
?
Intellectual/learning
- impairment with intellectual functions, or learning disabilities like dyscalculia, dysgraphia, dyslexia
Neurodevelopmental
- ADHD, ASD, Tourette’s syndrome, FASD
Psychiatric
- behavioural disorders, bipolar, depression, eating disorders, epilepsy, manias, phobias, schizophrenia, somnias
Sensory/speech
- vision, hearing, speech disabilities
Physical/diverse
- impairments affecting mobility and physical activities, including paraplegia, quadriplegia, muscular dystrophy, cerebral palsy, acquired brain injury, and neurological disability
None
Prefer not to say
Unknown
Examples given may not cover all possible conditions
Is the young person eligible for the NDIS?
Application in progress
NDIS eligible
NDIS ineligible
Unknown
Is the young person a carer?
Yes
No
Unknown
A carer is defined as a person who provides unpaid care and support to family members and friends who have a disability, mental illness, chronic condition, terminal illness, an alcohol or other drug issue or who are frail aged.
Does the young person have a
medical condition
?
Allergic and/or immune system conditions
Breathing
conditions
Hormone and/or metabolism
conditions
Sleep
conditions
Chronic pain and/or nerve-muscle conditions
Digestive system conditions
Heart and blood pressure conditions
Brain and nervous system conditions
Bone and muscle conditions
Infectious diseases
Skin conditions
Genetic, chromosomal and/or inherited conditions
Cancer
None
Prefer not to say
Unknown
Examples given will appear below may not cover all possible conditions
Allergies to food, medicine, or the environment, lupus, rheumatoid arthritis
Asthma, chronic obstructive lung disease (COPD), cystic fibrosis, sleep
apnoea
Diabetes, thyroid problems, obesity, metabolic syndrome, hormone imbalances
Insomnia, sleep
apnoea
, narcolepsy, restless legs syndrome
Migraines, fibromyalgia, chronic fatigue, nerve pain
Irritable bowel syndrome (IBS), Crohn’s disease, coeliac disease, acid reflux (GORD)
High blood pressure, heart disease, heart rhythm problems, congenital heart defects
Epilepsy, multiple sclerosis, Parkinson’s disease, Alzheimer’s disease, stroke
Arthritis, scoliosis, osteoporosis, tendonitis
Hepatitis, HIV/AIDS, tuberculosis, Lyme disease
Eczema, psoriasis, dermatitis, acne, skin infections
Down syndrome, cystic fibrosis, sickle cell
anaemia
, Marfan syndrome
Current and/or past history of cancer
Specific condition details
Does the young person have a
mental health condition
?
Mood disorder
- such as depression, bipolar
Anxiety disorder
Personality disorder
Psychotic disorder
- such as schizophrenia
Eating disorder
Trauma-related disorder
- such as PTSD
Substance abuse disorder
None
Prefer not to say
Unknown
Examples given may not cover all possible conditions
Is the young person receiving
treatment for their mental health condition/s
?
Psychotherapy/counselling
Behavioural therapy
Medication
Support groups
Art or music therapy
Mindfulness or meditation
No treatment
Prefer not to say
Unknown
Examples given may not cover all possible conditions
Treatment details for mental health condition
Medication details
YOUNG PERSONS REFERRAL REASON
Please select the
primary reason
for this young person's referral
Abuse and/or neglect
Assault and/or bullying
Behavioural issues
Education disengagement
Emotional wellbeing
Domestic and/or family violence
Drug and/or alcohol abuse
Family breakdown
Financial stressors
Grief and loss
Homeless or at risk of homelessness
Justice and/or legal issues
Relationship and/or social challenges
Self esteem issues
Self-harm
Suicidality
Unemployment
Please select any
secondary reasons
for this young person's referral
Abuse and/or neglect
Assault and/or bullying
Behavioural issues
Education disengagement
Emotional wellbeing
Domestic and/or family violence
Drug and/or alcohol abuse
Family breakdown
Financial stressors
Grief and loss
Homeless or at risk of homelessness
Justice and/or legal issues
Relationship and/or social challenges
Self esteem issues
Self-harm
Suicidality
Unemployment
Select up to 3 secondary referral reasons
ERROR
Referral reason details
Please share any extra details about why support is needed, such as key concerns, recent events, or context related to the referral reasons chosen above.
YOUNG PERSONS RISK PRESENTATION
To ensure we provide the right care and manage any risks for all young people being referred, the following important questions are presented. Please know that the information you provide will only be used to assess the situation and will not automatically prevent the young person from receiving services. Our goal is to keep both clients and staff safe while offering the necessary support.
Is the young person currently under the
guardianship
of the state or any government agency?
No
Yes
Is the young person subject to any
court orders
?
No
Yes
Has the young person been charged with or have pending charges relating to a
sexual offence
?
No
Yes
Does the young person present with violence or other
safety risks
to workers?
No
Yes
GUARDIAN DETAILS
PARENT/GUARDIAN DETAILS
First Name
Last Name
PARENT/GUARDIAN CONTACT DETAILS
Email
Guardian Type
Please select...
Guardian
Parent
Grandparent
Aunt or Uncle
Brother or Sister
Carer
Cousin
Friend
Teacher
Preferred Phone
Mobile
Home
Work
Phone (Work)
Phone (Home)
Phone (Mobile)
Please enter at least one phone number
PARENT/GUARDIAN HOME ADDRESS
If you have problems with the Google autocomplete, please select any address then type over the top of it with the correct details in the relevant boxe
s. You can also try googling the address first to ensure you have the correct suburb &/or postcode (e.g "Gladstone" or is it really "West Gladstone")
Street Address
Start typing the
street number
only (u
ses Google autocomplete)
.
If there is a unit or villa number, add it in the field below
Unit or Villa Number (only)
State - *autocompletes*
City/Suburb - *autocompletes*
Postcode - *autocompletes*
Contact Information