DBTeen Referral Form

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 4444 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.
Email*
example@example.com
Relationship to the Young Person*

Self ReferralAboriginal Health WorkerCase WorkerEducational ProfessionalGPMental Health NurseOccupational TherapistPsychiatristPsychologistSocial WorkerOther Medical Specialist
I have permission from the Young Person to refer them to this service:*

YES
I have permission from the parent(s)/guardian(s) to refer them to this service:*

YES
The Young Person and the Adult nominated below understand the program is completed together*

YES
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:*

FemaleMaleTransgender Male (FTM)Transgender Female (MTF)Non-binaryOther
Pronouns
Do you identify as LGBTQIA+?*

YesNoPrefer not to say
Address*

Street Address

Street Address Line 2

SuburbState

Post Code
Phone Number
Please enter a valid phone number.
Email
example@example.com
Is the Young Person of Aboriginal or Torres Strait Islander Australian descent?*

Yes, Aboriginal AustralianYes, Torres Strait Islander AustralianYes, both Aboriginal and Torres Strait Islander AustralianNo
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:*

Very wellWellNot wellNot at all
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.
Email*
example@example.com
Date of Birth*

DayMonthYear
Date
Relationship to the Young Person:*

ParentLegal GuardianOther
The Young Person being referred lives with me*

YesNo. 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:*

Very wellWellNot wellNot at all
YOUNG PERSON'S PRESENTING ISSUES
Does the Young Person have a GP Mental Health Treatment Plan?*

YesNoUnknown
Principal Diagnosis*
Additional Diagnosis
Does the Young Person have any disability*

YesNoUnknown
Does the Young Person take any medications?*

NoUnknownYes
If yes, please list:
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.
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.
Email
example@example.com
How did you hear about us?*
For information about Jotform’s Privacy and Security, please see the following links.

Jotform Privacy Jotform Security
Should be Empty:

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