West Tamar Youth Outreach Service E-Referral First Name:* Last Name:* Gender*MaleFemaleOtherPrefer not to disclose Date of Birth* Young person phone number Young person email address Address (Including Postcode)* Young person is: *Please SelectAboriginalTorres Strait Islander Both Neither Country of birth:* Main language spoken at home* Proficiency in Spoken English*Please SelectSpeaks only EnglishVery wellWellNot wellNot at all Is an interpreter required?*YesNo Young person's employment status:*Please selectEmployedNot EmployedNot in Labour Force Income Source:*Please SelectN/A (under 16's only)DSPOther CentrelinkWorkNil incomeOther NDIS Participant?*YesNo Does the young person have a health care card?*YesNoUnknown Does the young person have a GP Mental Health Care plan?*YesNoUnknown Referrer Name:* Referrer Profession:* Referral Organisation:* Referrer phone number:* Referrer Email:* Referrer Address:* How long has the young person been engaged in your service?* Young person referred to your service when/by? * Has the referral been discussed with the Young Person?*YesNo Has the young person consented to the referral? (Note: YP must consent for referral to proceed)*Yes Has the referral been discussed with the Parent/Custodian or Guardian (if relevant)? *YesNoN/A Has a Parent/Custodian or Guardian consented to the referral (if relevant)?*YesNoN/A Name of Parent/Custodian or Guardian and relationship to young person (if relevant):Please note this information is required if the young person is under 18. Parent 1 Name: Parent 1 Phone: Parent 2 Name: Parent 2 Phone: Legal Custodian or Guardian name: Legal Custodian or Guardian Phone: Other relevant details: GP Contact Details Psychiatrist & Contact details (if applicable) Current agencies involved/contact details previous agencies involved/contact details(1) Has the young person ever been known to or engaged with CAMHS/ACMHS or headspace? If so, please provide details: Reason for Referral* Mental health/medical diagnoses or concerns (e.g. past trauma/alcohol and drug) Medications (dose, prescribing clinician) Risk of harm to self (including frequency/duration of DSH, SI and behaviour as well as any previous Hospital presentations or admissions)* Risk of harm to others Is there a current risk assessment or safety plan? If so please attach it here: Legal / Medicolegal / Child Protection matters: Do you think the young person would be suitable for a telehealth mode of delivery? *YesNo Is there family or a guardian supporting the young person? *YesNo Are the young person and family willing and able to engage in telehealth as the model of care?*YesNo Do they have access to a device, data and privacy? *YesNo Please comment on current and recent risk factors (including suicidality and self harm in the previous 12 weeks) and your assessment of whether these risks can be reasonably managed via telehealth* Can the young person's goals be met through telehealth?*YesNo SDQ Score and Date administered K10 Score and Date administered SOFAS Score and Date administered HoNOS/CA Score and Date administered Other What goal/s does the young person identify to work towards?* What does the young person see this program being able to offer, what outcomes could be achieved? *SubmitReset
