Reconnect Referral Form

YOUNG PERSON DETAILS

First Name *

Last Name *

Address *

Street address *

City *

State *

Postcode *

Date of Birth *

Age *

Email Address

Phone Number

Alternate Contact

Preferred method of contact *

Other *

Have they been in Australia for less than 5 years

YesNo

Country of Birth *

Primary Language *

Does the Young Person identify as Aboriginal or Torres Strait Islander origin? *

Interpreter required?

YesNo

Current Residence *

FamilyFriendsCouch SurfingSleeping on the street

Has the young person previously been exposed to or experienced Family, Domestic or Sexual Violence? *

YesNoUnsure

Would the young person prefer a Reconnect Worker who is: *

MaleFemaleEither

RISK OF HOMELESSNESS

Current risk of homelessness *

ImminentPossibleProbable

Left Home Previously *

YesNo

How many times have they left home previously? *

YOUNG PERSON CONSENT

Has the young person given consent? *

YesNo (please obtain consent

SOURCE OF REFERRAL

Contact Person *

Role *

Contact Number *

Agency *

CHILD SAFETY SERVICES INVOLVEMENT

Current Involvement:

Current OrdersPast InvolvementNo Involvement

Comments

PLEASE LIST OTHER AGENCIES INVOLVED

Agency Name

Worker

Contact Details

FAMILY NETWORK / SIGNIFICANT OTHERS

Name

Male/Female

Relationship to YP

Address

Phone number

BACKGROUND INFORMATION EDUCATION DETAILS

Educational institution

Engaged Y/N

Current grade

Contact name

Contact phone

Presenting Issues *

ANTICIPATED RECONNECT SUPPORT

Young person support

Family support