DBTeen Referral Form

DBTeen Referral Form
DBTeen is a dialectical behaviour therapy (DBT) program for young people aged 14-18 who exhibit difficulty regulating their emotions and behaviour. The Young Person completes the program with an adult living in the same residence.

Young people who are receiving hospital and community mental health services (eg: CAMHS, CMHT, CATT, hospital inpatient) are not eligible to participate and will need to be discharged prior to commencing.

For further information about the progam contact Lifeline WA DBTeen on 08 9261 4498 or visit DBTeen.

If the Young Person is in crisis or in need of urgent assistance you can go to Head to Health https://www.headtohealth.gov.au/crisis-links to find services in your area. You could also contact Lifeline on 13 11 14, chat https://www.lifeline.org.au/crisis-chat/ or text 0477 13 11 14.

If you are experiencing difficulty submitting this form please email us at dbteen@lifelinewa.org.au
Today's date

DayMonthYear
Date
ABOUT THE REFERRER (includes Self-referrers)
Name

First NameLast Name
Organisation Name
Address

Street Address

Street Address Line 2

SuburbState

Post Code
Phone Number
Please enter a valid phone number.Format: 0000 000 000.
Email
example@example.com
Relationship to the Young Person
I have permission from the Young Person to refer them to this service:
I have permission from the parent(s)/guardian(s) to refer them to this service:
The Young Person and the Adult nominated below understand the program is completed together and they are required to be living together at least half the time
ABOUT THE YOUNG PERSON
YOUNG PERSONS LEGAL NAME

First NameLast Name
YOUNG PERSONS CHOSEN NAME (if different to legal name)

First NameLast Name
Date of Birth

DayMonthYear
Age
Gender:

Other
Pronouns
Do you identify as LGBTQIA+?
Address

Street Address

Street Address Line 2

SuburbState

Post Code
Phone Number
Please enter a valid phone number.Format: 0000 000 000.
Email
example@example.com
Is the Young Person of Aboriginal or Torres Strait Islander Australian descent?
Country of Birth:
DBTeen program participation requires a reasonable level of written, read and spoken English.
Main language spoken at home:
How well does the Young Person speak English:
ABOUT THE ADULT PARTICIPATING WITH THE YOUNG PERSON

Must be living in the same residence
ADULTS LEGAL NAME

First NameLast Name
ADULTS CHOSEN NAME (if different to legal name)

First NameLast Name
Phone Number
Please enter a valid phone number.Format: 0000 000 000.
Email
example@example.com
Date of Birth

DayMonthYear
Date
Relationship to the Young Person:

Other
The Young Person being referred lives with me

No. Please enter your address
DBTeen program participation requires a reasonable level of written, read and spoken English.
Main language spoken at home:
How well does the Adult speak English:
YOUNG PERSON'S PRESENTING ISSUES
Does the Young Person have a GP Mental Health Treatment Plan?
Principal Diagnosis
Additional Diagnosis
Does the Young Person have any disability
Does the Young Person take any medications?
If yes, please list:
Has the Young Person made a suicide attempt in the past?
Is there anything else you can tell us about the Young Person?
GP DETAILS

If not the referrer
Doctor's Name
Practice Name
Address

Street Address

Address

SuburbState

Postcode
Phone Number
Please enter a valid phone number.Format: 0000 000 000.
Email
example@example.com
Other Mental Health Professional Details

If not the referrer
Other Mental Health Professional's Name
Practice Name
Address

Street Address

Address

SuburbState

Postcode
Phone Number
Please enter a valid phone number.Format: 0000 000 000.
Email
example@example.com
How did you hear about us?
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DBTeen Referral Form

ABOUT THE REFERRER (includes Self-referrers)

ABOUT THE YOUNG PERSON

ABOUT THE ADULT PARTICIPATING WITH THE YOUNG PERSON

YOUNG PERSON'S PRESENTING ISSUES

GP DETAILS

Other Mental Health Professional Details