Youth Assistance Programme Online referral

Your Details
Current Status
How We Can Help
Finishing Up

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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withdrawn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?