Child and Youth DFV Counselling Referral Form

Understanding of Child and Youth Referral Process

Due to medium-term work in the Child and Youth space, our counselling books are not always open for referrals. We recommend calling 07 3050 3060 to confirm if we are accepting referrals before proceeding.
Before you begin, please confirm you understand that this program is for children and young people who have been impacted by domestic and family violence and it is not a general counselling service, psychology service, or psychiatry service.
If you are referring more than one child or young person, please note that a separate referral must be completed for each individual. This reflects that children and young people are recognised as victim-survivors in their own right in Queensland and may have experienced matters differently.
Client Details
Client Name (Child/Young Person's Name)

First NameLast Name
Date of birth or age if date of birth is unknown
Child/Young Person's Primary Address
Child/Young Person's Primary Post code
Please confirm the child or young person lives in either Logan or Redlands. We are only funded to provide free services to women and children living in these regions.
Child/Young Person's Gender Identity and preferred pronouns
Referring Parent/Carer Details
Parent/Carer's Full Name
What is your relationship to the child/young person?
What is your contact number?
What is your email address?
What is your residential address?
What is your preferred method of contact? E.g. Call, Text or Email
What is the best time to contact you? We are open 9am to 4pm weekdays.
Do you have legal parental responsibility for this child/young person?
Person Using Violence Details
Please let us know the full name, date of birth, address and relationship you and the child/young person has to the person or persons using violence.
Service Consideration

Are there any important family, safety, or communication considerations?
Child Safety
Family Law Court
Domestic Violence Orders
Please attach any Family Law Court, Domestic Violence Orders or Relevant Documentation.

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Behaviour, Support Considerations and Experiences
Please provide details of the current behaviours exhibited by the child or young person due to the impact of the domestic, family and violence. Tick all that apply.

Other
If you have any relevant documentation such as behavioural assessments, please upload here.

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Please tell us any considerations for supported engagement (e.g. medical, disability, cultural considerations):
Please provide details of the abuse experienced by the child/young person. Please tick relevant boxes and provide more information in the box.
Relevant Documentation
If you have any relevant documentation, please upload here. This may include:

- Domestic Violence Orders

- Behavioural Reports

- Family Law Court Orders

- Child Safety Orders
File Upload

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Understanding of Child and Youth Referral Process

Client Details

Referring Parent/Carer Details

Person Using Violence Details

Service Consideration

Behaviour, Support Considerations and Experiences

Relevant Documentation

Consent and Understanding