Youth Engagement Team E-Referral YET Referral First Name* Last Name:* Gender*MaleFemaleOtherPrefer not to say Date of Birth* Is the Young person:*AboriginalTorres Strait IslanderNeither Country of Birth* Main language spoken at home?* Interpreter required? *YesNo Proficiency in spoken english:*FluentVery Well WellNot WellNot at all Young Persons Email Young Person's Phone Number* Address (Including Post code)* Young person is:*EmployedNot EmployedNot in Labour Force Is the young person an NDIS participant?*YesNo Income Source*N/A (U/16's only)DSPOther CentrelinkWorkNil IncomeOther Does the young person have a health care card?*YesNo Does the young person have a GP Mental Health Care plan?*YesNoUnknownReferrer Information Referrer Name:* Referrer Profession:* Referral organisation:* Referrer Phone Number:* Referrer Email:* Referrer Address (Including Postcode):* How long has the young person been engaged with your service?* Referred to your service when/by?*Consent Information Referral discussed with young person:*YesNo Young person has consented to the referral? (Note: Young person must consent for referral to proceed)*Yes Has the referral been discussed with the parent/custodian or guardian (if relevant)? *YesNoN/A Has a parent/custodian or guardian consented to the referral?*YesNoN/A Name of Parent/Custodian or Guardian and relationship to young person (if relevant)Parent/s, Custodian/s or Guardian/s details:Please note this information is required if the young person is aged under 18 Parent Name 1: Parent 1 Phone Number/s: Parent Name 2 Parent 2 phone number/s: Legal Custodian or Guardian: Custodian/Guardian phone number: Any other relevant details:Other Agencies Involved: GP and contact details:* Psychiatrist & contact details:* Current agencies involved & contact details: Previous agencies involved & contact details: Has the young person been known to or engaged with CAMHS/ACMHS or headspace? Please provide details:*Mental health & clinical information Primary diagnosis / Presenting problem / History* Diagnosing Clinician:* Date of diagnosis:* Other mental health/medical diagnoses or concerns (for e.g. past trauma/alcohol & drug: Medications (Include dosages and prescribing clinician): Other current treatments: Risk of harm to self (Include 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? Please attach a copy below. Upload a Copy of the Risk assessment or safety plan: Current functional capacity:* Vulnerabilities:* Legal / Medicolegal / Child protection Matters:*Telehealth Criteria Do you think the young person would be suitable for a telehealth mode of delivery? *YesNo Is there family or a guardian supporting the young person?*YesNo Are the young person and family willing and able to engage in telehealth as the model of care?*YesNo Do they have access to a device, data & privacy?*YesNo 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 persons goals be met through telehealth?*YesNoCurrent Outcomes Measures (Please provide any that apply) SDQ Score Date SDQ was administered K10 Score Date K10 was administered: SOFAS Score Date SOFAS was administered HoNOS/CA Score Date HoNOS/CA was administered: Other:Goals What goal/s does the young person identify to work towards?* What do you and the young person see this program being able to offer, what outcomes could be achieved?*SubmitReset
