Youth Health Support Service Online referral Your Details Current Status How We Can Help Finishing Up Url Section 1: Your Details Let us get to know you a little. Tell us some basic details Referrer Legal First Name * Students Legal First Name * Referrer Legal Last Name * Student's Legal Last Name * Referrer Preferred Name Student's Preferred Name Student's Date Of Birth * Gender * 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 Student's Current Status Please complete or check the appropriate responses regarding the above named young person. Health Deteriorating personal appearance Frequent cold-like symptoms Glassy; bloodshot eyes Unexplained/frequent physical injuries/bruises Sleeping in class Odour of smoke Abnormal weight loss Other Academic Performance Decrease in class participation Short attention span, easily distracted Drop in grades – lower achievement Poor short-term memory Does not complete assignments Other Behaviour Defiance of rules Argumentative; defensive Verbally abusive Attention seeking Exhibits self-harm behaviour Irresponsible; blaming; denying Cheats; lies Inappropriate language, gestures Negativity Behaviour Change in friends Withdrawn, difficulty relating to others Talks/writes about drugs Is lethargic Other Strengths Exhibits leadership Good Communication Creative Musical Art Fashion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 Known Substances Used Meth/amphetamines Cannabis Alcohol Opiates Solvents Synthetic Highs 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 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 Health Support 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?