KYTT Program Referral Form
Complete this referral form with the young person’s details, current situation, supports, health, education, consents, and internal tracking information.
Young person’s details
Full Name
*
First Name
Middle Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
example@example.com
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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
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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
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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
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Consents and permissions
I understand that KYTT will store my information securely in their client system (SHIP) so they can support me
*
I understand
I agree that KYTT can contact me about this referral
*
I agree
I give permission for KYTT to contact the services listed above if needed to help coordinate my support
I give permission
Internal use/tracking
Submit Referral
Should be Empty: