The Spot - External Referral Form

External Referral Form

The Spot Service is available to anyone between the ages of 12 - 25 in Darwin or Katherine, NT. Email thespot@ntahc.org.au for more info.
Details of Young Person
Name*

First NameLast Name
Date of Birth*

DayMonthYear
Date
Gender*
Pronouns
Identity*

AboriginalTorres Strait IslanderBoth Aboriginal and Torres Strait IslanderOther
Best contact for Young Person*
Mobile or email (if alternative contact method (i.e. via parent of carer) please list at end of form in additional information)
Address*
If known, enter suburb (otherwise enter "Unknown")
Language spoken at home?*
(or type 'Unsure' in unknown)
Do they require an interpreter?*

YesNoMaybe
Emergency Contact Person

First NameLast Name
Emergency Contact Person Phone Number
Please enter a valid phone number.
Relationship to the Emergency Contact Person
Parents, guardian, mother, father, family relatives
Referral Details
Referral Date

DayMonthYear
Date
Referral Time

Hour Minutes

AM/PM Option
The Spot site preference*

NTAHC - Darwin City (every Thursday 11am - 7pm)headspace Darwin - Casuarina (every Wednesday 11am - 7pm)COMING SOON - headspace Katherine - Katherine (every Tuesday 11am - 7pm)
Why are you referring this Young Person?*
Please provide a brief explanation about why you are making this referral, particular services they require and any additional information on how we can best assist this Young Person
Particular Service request*

Sexual health TestingPregnancy TestingBrief counselling / guidanceFamily and Sexual Violence SupportContraceptive AdviceSexual Health and wellbeing educationGender/ Sexuality/ Identity questionsRespectful Relationships educationOther
Is the young person already engaged with any other services?
Any current risks or safety concerns?
Are there any privacy or safety considerations when contacting the young person?
(e.g. unsafe home environment, shared phone, needs discreet contact)
Safe times to contact?
Referrer Name*
Best contact for Referrer*
Organisation / workplace*
Relationship to the Young Person*
Additional Information

Is there anything else you want to add?
Comments
File Upload

(any relevant documents e.g. case notes, care plans, assessments, signed consents)
Cancelof
By signing below, I, the referrer outlined above, is referring this young person to The Spot Service with informed consent from the young person and/or their guardian. I confirm this referral has been discussed with the young person, and that the young perosn is aware they may be contacted by us.
Referrer Signature

Clear
Date Signed

DayMonthYear
Date
Should be Empty:

External Referral Form

Details of Young Person

Referral Details

Additional Information