Youth Assistance Programme Online referral Your Details Current Status How We Can Help Finishing Up Twitter Section 1: Your Details Let us get to know you a little. Tell us some basic details Referrer Legal First Name * Referrer Legal Last Name * Referrer Preferred Name Youth's Legal First Name * Youth's Legal Last Name * Student's Preferred Name Youth's Date Of Birth * Youth's Gender * Youth's Ethnicity * Relationship to person referred Now let us know how to best get back to you. Primary Contact Number * Secondary Number Email Address How do you prefer to be contacted? * Phone Email TXT message Section 2: The Young Person's Current Status Please complete or check the appropriate responses regarding the above named young person. Strengths Exhibits leadership Good Communication Creative Musical Art Fashion Strengths Writing etc Confident with others appears to like and be connected to school demonstrates good social skills can accept feedback or re-direction Other Health and well being cold/flu like symptoms Glassy unexplained injuries/bruises excessive sleepiness odour of smoke abnormal weight loss poor memory/concentration decline in hygiene/clothing Other Other Details: Behaviour (over and above usual adolescent changes): Changes in friend group talks/writes about drugs withdrawn difficulty relating to others lacks energy/motivation no longer participates in previously enjoyable activities talks about/undertakes self-harm overly argumentative lies/cheats abusive/assaultive engages in illegal activity Known Substances Used (or suspected to be used) Meth/amphetamines Cannabis Alcohol Opiates Solvents/Glue/Paint(huffing) Synthetic Highs/party pills Benzodiazepines LSD/Hallucinogens IV Use Prescription Medication Other Section 3: Some more details If you are referring a young person please indicate if you: Have discussed your concern with the young person Yes No Please comment on the result of the discussion Have discussed your concern with a parent/caregiver Yes No Please comment on the result of the discussion If you are the parent/caregiver, please select yes in this box to indicate you consent to this young person engaging with our service. Yes No Would you like to speak with a Youth Health Support Service member regarding your concern? Yes No Section 4: Finishing up! Thank you for your concern about our young people and your participation in the Youth Assistance Service process. Abiding by the Code of Health & Disability Services Consumer Rights, all information will remain confidential. We think we've got everything we need, but if we've missed something, please do let us know. When you're satisfied there's nothing else to add, hit the submit button to get things underway Anything else you'd like to add?