Karinya Young Mums (KYM) Referral Form
This is the standard online referral form for the Karinya Young Mums (KYM) Program.You can complete this form yourself, or a worker can complete it with you or on your behalf.Please provide as much accurate information as you can. This helps us understand your situation and respond as quickly and appropriately as possible.
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
Current address
How do you describe your gender?
*
Please Select
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?
*
Please Select
Aboriginal
Torres Strait Islander
Both
Neither
Prefer not to say
Where are you staying right now?
*
Is someone helping you with this form?
Please Select
Yes
No
Referrer / Support Person Details
Referrer Name
*
Organisation
Referrer Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Referrer Email Address
*
example@example.com
Worker Name
Worker Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Worker Email
example@example.com
Other Service Name
Safety, Legal, and Child Protection
Are there any current court orders or child protection conditions in place?
*
Please Select
Yes
No
Court orders / child protection details
Do you have any outstanding court issues, pending charges, court orders or probation conditions? If yes, Please detail these.
Is there anyone wanting to cause you harm?
*
Yes
No
If yes, do you have a current PFVO/AVO/FVO in place?
Yes
No
Pregnancy
Are you currently pregnant?
*
Please Select
Yes
No
How many weeks pregnant are you?
Are you currently connected with pregnancy support?
GP
Midwife
Hospital Antenatal Clinic
None
Other
Other pregnancy support
Baby / Parenting
Do you have a baby?
*
Please Select
Yes
No
Baby’s Name
Baby’s Date of Birth
-
Month
-
Day
Year
Date
Are you currently connected with baby/parenting supports?
Child Health Nurse
GP
Family Support Service
None
Other
Other baby/parenting support
Partner / Co-parent
Do you currently have a partner or co-parent involved?
*
Please Select
Yes
No
Prefer not to say
Partner’s Name
Partner’s Phone Number
Is your partner living with you?
Please Select
Yes
No
Prefer not to say
Are there any safety concerns regarding your partner?
Please Select
Yes
No
Prefer not to say
Partner safety concern details
Living Skills & Independence
Have you lived independently before?
*
Please Select
Yes
No
Prefer not to say
Independent living details
Health & Wellbeing
Are you experiencing any mental health challenges?
*
Please Select
Yes
No
Mental health details
Are you currently experiencing any suicidal thoughts?
*
Please Select
Yes
No
Have you ever experienced any suicidal thoughts?
*
Please Select
Yes
No
Do you have any physical health concerns?
*
Please Select
Yes
No
Physical health details
Are drugs or alcohol affecting you?
*
Please Select
Yes
No
Drugs and alcohol details
Education, Work & Income
Are you currently working?
*
Please Select
Yes
No
Working details
Are you receiving Centrelink payments?
*
Please Select
Yes
No
Centrelink payment type
Centrelink CRN
Housing & Support
Housing Application
Please Select
Yes
No
In progress
Not sure
What’s been happening for you lately, and how can we support you?
*
Consent
I agree that KYM can contact me about this referral
*
Yes
I give permission for KYM to contact the services listed above if needed to help coordinate my support
Yes
Submit Referral
Should be Empty: