yAsp Referral yAsp E-Referral Client Details: Clients Name* Preferred Pronouns: Address* Date of Birth* Contact Number* Email*Emergency Contact: Name* Contact Number(s)* Email Address* Relationship to the client*Please answer the following questions: Does the young person identify as Aboriginal or Torres Strait Islander?*YesNo Does the Young Person agree to this Referral? (yAsp is a voluntary program)*YesNo Is the parent/guardian aware of this referral?*YesNo Is it appropriate to contact the parent/guardian?*YesNo Details if no:* Does the young person have stable accomodation? *YesNo Are they currently attending school/training?*YesNo Details* Have they been a previous yAsp client?*YesNoReferral Information Please indicate the reason for referral* What goals would the young person like to acheive while they are in the program?* Please list any other agencies/workers the young person is involved withPlease answer the following questions in relation to risk. Are there any risks associated with suicide or self harm?*YesNo Please provide further details* Are there any other risks we need to be aware of?*YesNo Further Details*Please provide details about the person making this referral: If you are referring yourself, please tick this box. Self-Referral Your Name* Your Phone* Your Email Address:* Organisation/Agency: *SubmitReset
