Safe and Connected Youth Program

Self-Referral Form

Are you a young person aged between 8 to 15 experiencing family conflict or looking for a therapeutic respite accommodation ?

Complete our Self Referral Form below, and our team will get in touch with you.

Refer yourself

Complete THIs self referral form to get the support you need

Who is completing this form?
Who is completing this form?

Your Details

Please complete all the sections that you are able to. We recognise that some information will not be available for all families.
Name
Gender or Pronouns
Date of Birth
DD slash MM slash YYYY
Phone
Email
Address

Other Party Details (Young person, parent or carer)

Please complete the details of the other party here.
Name
Gender or Pronouns
Date of Birth
DD slash MM slash YYYY
Phone
Email
Address
Do you identify as Aboriginal or Torres Strait Islander? (You are welcome to specify cultural connections)
Do you identify as Aboriginal or Torres Strait Islander? (You are welcome to specify cultural connections)
Do you identify as culturally or linguistically diverse?
Who holds parental responsibility/guardianship for the young person?
Does the young person, or do you, have any disability, mental health condition, or other support needs that we should be aware of to better assist you?
Are there any current court orders in place for the young person or family?
Is the other party aware of this referral?
What can we help you with?
How did you hear about CRS?