SASS Children and Families Counselling Program referral form

Current school (if attending):
Age:
Children and Families Counselling Program

Referral Form
This form is for the use of professionals or service providers. For self-referrals or families, please phone us (03) 6231 0044 during business hours for direct support from our friendly team.

If you have experienced sexual violence or harm in the past 7 days, please call the SASS 24/7 Helpline (1800 697 877) for immediate information and support.

Once completed, save this referral form to your files, then upload via the secure PDF upload https://www.sass.org.au/make-a-referral-children-and-families. For security reasons, do not email this referral form directly to us.

This form is to be used for referrals to SASS' General Children and Families Counselling Service. This program supports young people directly impacted by sexual harm and/or the family supporting them. For support for young people engaging in risky or harmful sexual behaviour please make a referral to the Prevention, Assessment, Support and Treatment of Sexual Behaviours program.

Other referral forms are available from www.sass.org.au/make-a-referral;
- Adult Counselling program and Redress Support Service.
- Forensic Therapeutic program.
- Prevention, Assessment, Support and Treatment of harmful sexual behaviours program.
SASS has eligibility criteria for all programs. Thank you for providing as much detail as possible. The information you share helps the intake team manage demand for our services. If you are unsure whether your referral is appropriate, please contact us to discuss.
Date of referral:

DayMonthYear
Date
Referring person or agency:
Referrer relationship to client:
Referrer email:
example@example.com
Referrer phone number:
Please enter a valid phone number.
Has the client indicated they are wanting support regarding their experience of sexual harm?

YesNo
Has consent been given for this referral being made?

Child/young person consentCare giver consentNo
When responding to this referral, who should we first make contact with?

ReferrerYoung personPrimary carer
Has the client accessed SASS previously?

YesNo
How did the referrer/the client hear about SASS?

Child Safety ServiceAdvice and Referral LineInternet SearchSocial MediaInterstate serviceMedical Practitioner/ Health ServiceNDIS/Disability ServiceNGO servicePolice/Legal/JusticePsychologist/ CounsellorRedress Scheme/ KnowmoreIs your referral a result of contact with Primary Care Family and Sexual Violence Support?Other
- Name
  
  First NameLast Name
- Gender
  
  FemaleMaleTransgenderNon-binaryPrefer not to say
- Preferred pronouns:
  
  She/Her/HersHe/Him/HisThey/Them/TheirsPrefer not to sayOther, please specify:
- Date of Birth:
  
  DayMonthYear
- Current school (if attending):
- Cultural identity:
  
  NoneAboriginal and Torres Strait IslanderAboriginalTorres Strait IslanderPrefer not to sayCulturally and linguistically diverse backgroundPlease specify:
- Does the client have a disability, or any other mental and/or physical health presentations?
  
  YesNoPrefer not to sayNot known
- If yes, please specify:
- Does the client have any literacy limitations?
  
  Reading difficultiesWriting difficultiesUnable to read or writePrefer not to sayNot knownOther, please specify:
- Phone Number
  
  Area CodePhone Number
- Is this a safe number to receive calls, texts and voice messages?
  
  YesNo
- Email:
- Does anyone else have access to this email account that may compromise the client’s privacy?
  
  YesNo
- Preferred form of contact
  
  PhoneEmail
- Residential address
  
  Street Address
  
  Street Address Line 2
  
  Town/SuburbState
  
  Post Code
- Is it safe to send hard copy mail to this address?
  
  YesNo
- Postal address
  
  Same as residential address
- Street Address
  
  Street Address Line 2
  
  Town/SuburbState
  
  Post Code
- Is it safe to send hard copy mail to this address?
  
  YesNo
- Who else resides with the client?
- Contact name:
  
  First NameLast Name
- Phone Number
  Please enter a valid phone number.
- Relationship to client:
- If the client has a significant support person, carer, parent or guardian please provide their details below.
- Name
  
  First NameLast Name
- Relationship to client:
- Phone:
  
  Area CodePhone Number
- Email:
  example@example.com
- Is the primary contact aware of all information on this referral form?
  
  YesNo
- Will this person be organising the appointments at SASS?
  
  YesNo
- What are the client’s key difficulties at present?
  (I.e., mental health; self-harm; drug & alcohol; homelessness; depression; hallucinations; flashbacks; self-regulation; delusions; etc. Please Include frequency, duration and severity of symptoms/behaviours)
- Is this a first disclosure?
  
  YesNo
- Approximately how long ago did the client make the disclosure?
- Sexual abuse history (timeframe since the last assault):
  
  72 hours or less1 year or less1-5 yearsMore than 5 yearsUnspecifiedOngoing and current
- Relationship of alleged perpetrator to the client:
  
  Familial / Family FriendOther, please specify:
- Persistence of sexual abuse:
  
  Ongoing & RepeatedOnce off
- Self-harm:
  
  Active (please provide details below)Infrequent / not current concern
- If self-harm is assessed as active, please provide additional details:
  E.g. frequency, severity, hospitalisation
- Suicidal thoughts:
  
  Active (please provide details below)Infrequent / not current concern
- If suicidal thoughts is assessed as active, please provide additional details:
  (e.g. frequency, severity, hospitalisation)
- Please provide details of the sexual assault or harmful sexual history if possible:
- If the client you are referring has experienced sexual harm from another young person, please name the young person who caused the harm (if known)?
  This information is collected to help us identify and manage any safety, privacy and appointment scheduling concerns that may arise if both children are accessing the service.
- Did the abuse include any technology-facilitated abuse? If yes, did it involve:
  
  Coercive controlImage basedOnlineOnline and image basedStalking/monitoringOther (please describe)
- Are there current Legal Orders in place:
  
  Child Safety ServicesFamily CourtOther, please specify:
- Have any of the following taken place:
  
  Police InvolvementForensic Medical ExaminationOther:
- Has the client experienced or witnessed Family Violence?
  
  YesNoUnknown
- If yes, is this:
  
  CurrentHistoric
- Has a notification to the Strong Families Safe Kids Advice and Referral Line been made?
  
  Yes (please provide details below)NoUnknown
- Notification date:
  
  DayMonthYear
  Date
- Name of worker:
- Reference number:
- Are there any safety concerns for the client?
  (I.e. threat of further sexual assault/abuse, etc)
- What is the client’s family support network?
- What is the client’s social and peer support network?
- Current professional supports:
  
  NoYes. Please provide details:
- What are the client’s strengths/ current coping strategies?
  E.g. good self-regulation, engages in good self-care, uses hopeful coping strategies, good communication skills, strong interests or hobbies etc
- Are there any additional factors that have led to the client seeking a referral?
- Does the client need support to access SASS?
  E.g. disability, interpreter, support person, medical, cultural, anxiety/mental health, etc.
- Are there any indications for safety issues for SASS workers with the client?
  E.g. anger issues, psychosis, client views worker as threat etc.
- Who will be the main contact for the client to book appointments with?
  
  The clientLegal guardianCSSOther, please specify:
- What are the best times/days for SASS appointments?
- What are the preferred modalities for SASS appointments?
  
  Face to FaceVideo callPhone callCombination
- Does the client have reliable access to internet and technology?
  
  YesNo
- Does the client prefer a counsellor of a particular gender?
  
  FemaleMaleEitherUnknown
- Referral taken by (SASS representative):
- What is identified as the primary need for support?
  
  Brief interventionComprehensive counselling serviceGroup / Wellbeing ProgramTrauma-informed parenting support for the client’s guardian
- Should be Empty: