PAST Program referral form

Age:
Number
PAST program referral form (child)

Prevention, Assessment, Support and Treatment (PAST) of harmful sexual behaviours.
This form is for the use of professionals or carers. For self-referrals 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 www.sass.org.au/prevention-assessment-support-and-treatment-past-of-harmful-sexual-behaviours. Do not email this referral form directly to us.

This form is to be used for referrals to SASS' Prevention, Assessment, Support and Treatment (PAST) of harmful sexual behaviours program.

Other referral forms are available from www.sass.org.au/make-a-referral
- Adult Counselling program and Redress Support Service.
- General Children and Families Counselling Service.
- Forensic Therapeutic 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 consented to this referral being made?

YesNo
Who is this referral for?

A Child/Young PersonAn Adult/Guardian
When responding to this referral, who should we first make contact with?

ReferrerYoung PersonPrimary Carer
Has the client accessed SASS previously?

YesNoUnknown
Is client aware that the PAST program is delivered by SASS in conjunction with Mission Australia and information may be shared across these two agencies?

YesNoUnknown
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:
  
  He/Him/HisShe/Her/HersThey/Them/TheirsPrefer not to sayOther (please specify)
- Date of Birth
  
  DayMonthYear
  Date
- Current school (if attending):
- Cultural identity:
  
  NoneAboriginal and Torres Strait IslanderAboriginalTorres Strait IslanderPrefer not to sayCulturally and linguistically diverse background, please specify:
- Does the client have a disability or any additional needs?
  
  CognitivePhysicalNonePrefer not to sayIf yes, are there any access issues?
- Does the client have any other known or suspected diagnoses?
  
  AttentionDeficit Hyperactivity Disorder (ADHD)Autism Spectrum Disorder (ASD)NonePrefer not to sayOther, please specify:
- 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
- Emergency contact name:
  
  First NameLast Name
- Relationship to client:
- Tick here is this is Parent/carer/guardian referral and continue to the 'Referral details' section.
- Name:
  
  First NameLast Name
- Phone:
  
  Area CodePhone Number
- Email:
  example@example.com
- Relationship to client:
- Is the primary contact aware of all information on this referral form?
  
  YesNo
- Is the client living with the primary contact?
  
  Yes - (full-time)Yes– Shared Care (part-time)No, please provide details:
- Who else is the client residing with?
- Will this person be organising the appointments at SASS?
  
  YesNoUnknown
- Who is the client's legal guardian?
  
  ParentChild Safety Service (CSS)UnknownOther, please specify:
- If CSS, provide name and contact details:
  
  First NameLast Name
- CSS phone Number
  Please enter a valid phone number.
- CSS email
  example@example.com
- Are there current Legal Orders in place:
  
  Child ProtectionFamily CourtOther, please specify:
- Please provide details of the problem/harmful sexual behaviour:
  What happened, frequency, duration, escalating/deescalating, evidence of coercion, context –home, respite, school etc.
- What was the client's response when the behaviour was discovered?
  Embarrassment,defensiveness, withdrawal etc.
- What was the family’s reaction to this behaviour?
  Minimizing, denying, wanting to get client help?
- Was the behaviour targeted towards someone else?
  
  YesNoUnknown
- Please list any young people who have been impacted by these behaviours (victims) including age and gender (if known):
  This information is collected to help us identify and manage any safety, privacy and scheduling concerns that may arise if both young people are accessing the service.
- Is there any other non-sexual behaviour the client has or is engaging in? If so please describe:
  E.g. criminal, antisocial etc.
- Please provide a brief summary of the family history/dynamics, including key relationships for the client in the family:
  E.g. grandfather, mother, siblings etc. Are these relationships and connections seen to be positive?
- Has the client experienced or witnessed Family Violence?
  
  YesNoUnknown
- If yes, is this:
  
  CurrentHistoric
- Has Child Protection Notification been made in relation to HSB?
  
  Yes (please provide details below)NoUnknown
- Name of ARL/CSS worker:
  Name if known.
- ARL/CSS reference number:
  Refernce number if known.
- Have police been made aware of this matter?
  
  YesNoUnknown
- What are the client’s strengths, current coping strategies and support network?
  Include social and professional supports
- What support does the client need from SASS?
  E.g. counselling, court support, police report
- 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: