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West Tamar Youth Outreach Service E-Referral

First Name:*

Last Name:*

Gender*

Date of Birth*

Young person phone number

Young person email address

Address (Including Postcode)*

Young person is: *

Country of birth:*

Main language spoken at home*

Proficiency in Spoken English*

Is an interpreter required?*

Yes

Young person's employment status:*

Income Source:*

NDIS Participant?*

Yes

Does the young person have a health care card?*

Yes

Unknown

Does the young person have a GP Mental Health Care plan?*

Yes

Unknown

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?*

Yes

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)? *

Yes

N/A

Has a Parent/Custodian or Guardian consented to the referral (if relevant)?*

Yes

N/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? *

Yes

Is there family or a guardian supporting the young person? *

Yes

Are the young person and family willing and able to engage in telehealth as the model of care?*

Yes

Do they have access to a device, data and privacy? *

Yes

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?*

Yes

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? *

Cornerstone Youth Services acknowledge the traditional owners of the land on which we work and live: The Tyrenoterpanner, Panninher and the Leetermairreener clans of the Stoney Creek Nation and the Punnilerpanner clan of the North Nation, and recognise the continuing connection of Aboriginal and Torres Strait Islander people to land, water and community. Cornerstone Youth Services acknowledges Aboriginal and Torres Strait Islander peoples as the First Peoples of Australia and we pay our respects to their elders past and present.