S&CY Program Referral Form

Refer a person in need

The Safe & Connected Youth Program emphasises restoration, reunification and reconciliation between young people under the age of 16 and their families. The Program works to support young people and families to provide a positive and nurturing environment. We work to improve parent-child relationships to reduce risk of homelessness and empower young people to develop their full potential as individuals, as well as contributing to our community.

DETAILS OF YOUNG PERSON
Name*
Gender
Date of birth
Date of birth
DD slash MM slash YYYY
Address
Phone*
Email
Has the young person agreed to this referral?*
Are the parents/carers aware of referral?*
DETAILS OF PARENTS/CARERS
Name*
Relationship to young person*
Gender
Date of birth
Date of birth
DD slash MM slash YYYY
Address*
Phone*
Email
Does the Parent/Carer understand and agree to this referral?*
Does the Parent/Carer understand and agree to this referral?
- Yes
- No
DETAILS OF REFERRER
Name*
Referrer Organisation/Service
Service Provided
Phone*
Email*
Address
Will you or another person from your service have continued involvement with the young person?*
What do you hope the young person and family will get from S&CY Program?*
PROFILE OF THE YOUNG PERSON AND FAMILY
Where is the young person living?
Relevant family member details
Historical information
Description of Presenting Issues
Details of service history involvement
Current orders or upcoming court dates for the young person or family
Current strengths of the young person or family
Any other relevant information

S&CY Program Referral Form

Refer a person in need

DETAILS OF YOUNG PERSON

DETAILS OF PARENTS/CARERS

DETAILS OF REFERRER

PROFILE OF THE YOUNG PERSON AND FAMILY