KYTT Program Referral Form
Complete this referral form with the young person’s details, current situation, supports, health, education, consents.
Please complete this referral form with the young person’s details, current situation, supports, health, education, consents and required documents. A current, active Housing Tasmania application and current case plan are required before a KYTT referral can be submitted.
Young person’s details
Full name
*
Date of birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Phone number
Please enter a valid phone number.
Format: (000) 000-0000.
Email address
example@example.com
How does the young person describe their gender?
Please Select
Female
Male
Non-binary
I describe my gender as
Prefer not to say
Does the young person identify as Aboriginal and/or Torres Strait Islander?
Yes
No
Where is the young person staying right now?
*
Which best describes their current living situation?
*
Please Select
Couch surfing
Staying with family
Staying with friends
Renting privately
Temporary accommodation
Other
If other, please describe their living situation.
Is someone helping the young person with this form?
*
Yes
No
Referrer details
Referrer name
*
Organisation
*
Referrer phone number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Referrer email address
*
example@example.com
Housing Tasmania application
Does the young person have a current, active Housing Tasmania application?
*
Yes
No
Housing Tasmania application reference number
A current, active Housing Tasmania application is required before a KYTT referral can be submitted. Please support the young person to complete or reactivate their application before returning to this form.
Required document
Upload current case plan
*
Upload a File
Drag and drop files here
Choose a file
Cancel
of
Current supports and services
Are there any services or workers currently supporting the young person?
Child Safety Service
Youth Justice
mental health service
alcohol and other drug service
school or training provider
NDIS/provider supports
Housing Tasmania
other
none known
Other supports or relevant information.
Health and wellbeing
Are there any mental health concerns?
Yes
No
Prefer not to say
Please provide relevant details.
Are there any physical health concerns?
Yes
No
Prefer not to say
Please provide relevant details.
Are drugs or alcohol currently affecting the young person?
Yes
No
Prefer not to say
Please provide relevant details.
Education, income and work
Is the young person currently at school, TAFE, university or training?
Yes
No
Is the young person receiving Centrelink payments?
Yes
No
Is the young person currently working?
Yes
No
Please provide any relevant details.
Consents and permissions
I understand that KYTT will store the young person’s information securely in SHIP so the service can provide support.
*
I agree that KYTT can contact the young person about this referral.
*
I give permission for KYTT to contact the services listed in this referral, where needed, to help coordinate support.
*
Young person’s details
Full Name
*
First Name
Middle Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Phone number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
example@example.com
Back
Next
Demographic and living situation
How do you describe your gender?
*
Female
Male
Non-binary
I describe my gender as
Prefer not to say
I describe my gender as
Do you identify as Aboriginal and/or Torres Strait Islander?
*
Aboriginal
Torres Strait Islander
Both
Neither
Prefer not to say
Where are you staying right now?
*
Which best describes your current living situation?
*
Please Select
Couch surfing
Staying with family
Staying with friends
Renting privately
Temporary accommodation
Other
If something else, please describe your living situation
Is someone helping you with this form?
Yes
No
Back
Next
Referrer details
Referrer Name
*
Organisation
Referrer Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Referrer Email Address
*
example@example.com
Current supports/services
Are there any services or workers currently supporting you right now?
*
Please Select
Child Safety Services
Child Protection
Youth Justice
Housing Connect
Centrelink
Other
Other service name
Worker name
Worker phone
Please enter a valid phone number.
Format: (000) 000-0000.
Worker email
example@example.com
Back
Next
Health and wellbeing
Are you dealing with any mental health challenges?
*
Yes
No
Mental health details
Do you have any physical health concerns?
*
Yes
No
Physical health details
Are drugs or alcohol affecting you?
*
Yes
No
Drugs or alcohol details
Education, income, and work
Are you currently at school, TAFE, uni or training?
*
Yes
No
Education / training details
Are you receiving Centrelink payments?
*
Yes
No
Centrelink payment type
Centrelink CRN
Are you currently working?
*
Yes
No
Work details
Back
Next
Consents and permissions
I understand that KYTT will store the young person’s information securely in SHIP so the service can provide support.
*
I understand
I agree that KYTT can contact the young person about this referral.
*
I agree
I give permission for KYTT to contact the services listed in this referral, where needed, to help coordinate support.
*
I give permission
Internal use/tracking
Submit KYTT Referral
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