Youth Projects and Support (YPS) Referral Form

IMPORTANT INFORMATION ABOUT YOUR REFERRAL - PLEASE READ.

YPS provides case management support and coordination for children and young people aged 5 - 25, in coordination with other registered child and youth safety partnerships in the nine communities in the Central Desert Regional Council region. YPS does not provide intensive crisis-intervention services. Where suitable, YPS may also provide referrals or opportunities for the child or young person to engage in beneficial youth development activities, sporting opportunities or project engagement.

YPS can only engage with the referred child or young person, if consent has been provided by a parent, guardian or carer if the person is under 16, or consent provided by the young person aged 16 - 25. If you are referring as an organisation or agency, please ensure you also have consent prior, or kindly support a young person over 18 to complete this referral form and provide consent.

YPS is not a crisis intervention service; if a child or young person is in crisis, at risk of harm or there is an emergency, please contact 000.

When the referral has been made, YPS will undergo an assessment of the child or young person, to ensure the suitability of the YPS service. Please note that the receipt of the referral does not indicate acceptance to YPS services.

Please be advised that there may be a waitlist or waiting period, given the demand and size of the region. You will be advised by a YPS staff member via phone or email, or in-person. We advise to speak with your GP, or attend the local Clinic or hospital, should the situation change.

Child or Young Person Details

Full Name*

Invalid Input

Preferred name

Invalid Input

Gender:*

Invalid Input

Date of birth*

Invalid Input

Phone

Invalid Input

Email

Invalid email address

Is it okay to contact you via SMS?*

Yes

No

Invalid Input

Residential Address (including community, postal code and Lot number)*

Invalid Input

Postal Address

Invalid Input

Previous Client, or engaged in CDRC's Youth, Sport & Rec Programs?*

Yes

No

Invalid Input

Cultural Background:

Invalid Input

Aboriginal or Torres Strait Islander?*

Yes

No

Other

Invalid Input

Language spoken at home:*

Invalid Input

Interpreter required?*

Yes

No

Invalid Input

Client's Parent, Guardian, Carer or Key Contact Person (in case of emergency)

Name*

Invalid Input

Relationship to Child or Young Person*

Invalid Input

Is the young person subject to any guardianship or custody orders?*

Yes

No

Invalid Input

Referrer Details

Is this a self-referral?*

Yes

No

Invalid Input

Is someone assisting you to make this referral or complete this form?*

Yes

No

Invalid Input

Assistant Name*

Invalid Input

Assistant Phone Number

Invalid Input

Assistant Email Address

Invalid Input

Referrer Name*

Invalid Input

Referrer Phone Number

Invalid Input

Referrer Email Address

Invalid Input

Referrer Relationship to Child or Young Person

Invalid Input

Does the child or young person have an existing GP?*

Yes

No

Invalid Input

GP Name*

Invalid Input

GP Phone Number

Invalid Input

GP Email Address

Invalid Input

Is the young person receiving individual support from another service, agency or organisation?*

Yes

No

Invalid Input

Agency 1*

Invalid Input

Contact Person Name

Invalid Input

Phone Number

Invalid Input

Email Address

Invalid Input

Agency 2

Invalid Input

Contact Person Name

Invalid Input

Phone Number

Invalid Input

Email Address

Invalid Input

Further Details

Invalid Input

Risk Factors (self / referrer to complete)

Suicidal thoughts*

Yes, in the last 4 weeks

Yes, in the past

No

Other...

Invalid Input

Suicidal Behaviours (plans/intentions to act)*

Yes, in the last 4 weeks

Yes, in the past

No

Other...

Invalid Input

Do you have a safety plan?*

Yes

No

Other...

Invalid Input

Subject to family violence, abuse or neglect*

Yes

No

Invalid Input

Please Provide Details*

Invalid Input

Any recent hospitalisations for family violence, domestic violence, mental health or other medical conditions?*

Yes

No

Invalid Input

Please Provide Details

Invalid Input

Any Other Risk or Potential Risk Details

Invalid Input

Young Person Supports and Consents

YPS case management support is a free and confidential service for young people in the Central Desert Region aged 5 - 25. The parent, guardian or carer consents for the child referred to receive support. For young people 16 - 25, the young person consents to receiving support. YPS does also work sensitively, with other child and safety stakeholders in regional partnerships where appropriate, underpinned by the NT Family Safety Framework. YPS cannot provide support without first receiving signed consent, this can be provided electronically via signature below, or in person in written form.

YPS advises that due to capacity and the size of the region, there are often waiting times or a waitlist. YPS is not a crisis support service. If the child or young person is in crisis or acute risk of harming themselves or others, please contact emergency services on 000. YPS also recommends Kids Helpline 1800 55 1800, 13YARN 139276, and Headspace, and visiting your local clinic or GP to seek support, the local hospital should your situation change.

*

I have read, understood and agree to the terms of engagement

Invalid Input

Does the young person consent to referral*

Yes

No

Invalid Input

If under 16, do carers consent to referral?*

Yes

No

Invalid Input

Does the young person consent to sharing information confidentially with other agencies to ensure appropriate care?*

Yes

No

Invalid Input

Parent/Guardian/Carer 1. Name*

Invalid Input

Parent/Guardian/Carer 1. Signature*

Sign Above

Invalid Input

Parent/Guardian/Carer 2. Name

Invalid Input

Parent/Guardian/Carer 2. Signature

Sign Above

Invalid Input

Young Person Signature*

Sign Above

Invalid Input

Today's Date*

Invalid Input

CAPTCHA*

Invalid Input

This Central Desert Regional Council (CDRC) Youth Projects and Support (YPS) service has been made possible by funding and support provided by the Australian Government, National Indigenous Australians Agency (NIAA) 'Children and Schooling Programme'.

Thank you.

Back To Top

Central Desert Regional Council