Karinya Crisis Accommodation Referral Form
Complete this form to refer a young person for crisis accommodation—submission is reviewed and does not confirm availability.
Referring Service and Worker
* Indicates a mandatory question.
Referring service/organisation name
*
Referring worker’s name
*
Position/role
Please enter a direct phone number.
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email address
*
example@example.com
Preferred contact method
*
Phone
Email
Young person’s details
Young person’s full name
*
First Name
Middle Name
Last Name
Date of birth
*
-
Month
-
Day
Year
Date
Age
*
Preferred name and pronouns
Phone number
Please enter a valid phone number.
Format: (000) 000-0000.
Current location / suburb
*
Is the young person currently safe?
*
Yes
No
Unsure
Please provide details and advise what immediate supports are in place.
*
Consent and referral details
Has the young person agreed to this referral being made?
*
Yes
No
Does the young person want to stay at Karinya Crisis Accommodation?
*
Yes
No
Unsure
Please explain why consent has not been obtained.
*
Has the young person previously stayed at Karinya?
Yes
No
Unsure
When is accommodation required?
*
Within 24 hours
Within 24–48 hours
Within 3–4 days
Within 5–6 days
Within 7–14 days
More than two weeks
Has Housing Connect been contacted?
*
Yes
No
Unsure
Please provide any relevant details.
Current situation and support needs
Please tell us what is happening for the young person and why crisis accommodation is being sought
*
Are there any current concerns that may affect the young person’s safety or the safety of others in a communal living environment?
*
Mental health concerns
Alcohol or other drug use
Behavioural concerns, including aggression
Current medical or physical health needs
Family violence or safety concerns
Legal, bail, or court matters
Child Safety Service involvement
None known
Other
Please provide relevant details, including current supports, medications, health needs, safety planning, or risks
*
Is the young person linked with any of the following services?
Child Safety Service
Youth Justice
Mental health service
Alcohol and other drug service
NDIS/provider supports
Housing Connect
None known
Other
What other accommodation or support options have been explored?
*
Orders and legal requirements
Is the young person currently subject to any orders?
*
Yes
No
Unsure
If yes, please identify the type of order and provide relevant details. Examples may include child protection orders, bail conditions, family violence orders, restraint orders or court orders.
Additional information
Any other information the Karinya team should consider
Case plan
Case plan
Upload case plan
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Choose a file
PDF, DOC, DOCX, or image files
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Confirmation
*
I confirm that the information in this referral is accurate to the best of my knowledge and that the young person has consented to the referral, unless otherwise explained above.
Submit Referral
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