Urgent Care Referral Form
Young Person Details
Young Person's Name
*
First Name
Last Name
Young Person's Date of Birth
*
-
Day
-
Month
Year
2 digit day, 2 digit month, 4 digit year
Date
Date of Referral
*
-
Day
-
Month
Year
2 digit day, 2 digit month, 4 digit year
Date
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Referrer Details
Referrer Name
*
First Name
Last Name
Relationship to Young Person
*
Referrer Phone
*
-
Area Code
Phone Number
Referrer Email
*
A copy of this referral will be sent to this email address.
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Consent and Guardianship
Young person's consent to referral
*
Yes
No
Consent details
Who is the legal guardian of the child/young person?
*
Has the legal guardian consented to the referral?
*
Yes
No
Not applicable
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Support and Background
Ongoing support / case manager — name and contact details
YP is aware there are enforceable rules and expectations (full details discussed on arrival, but includes handing in of phones at night, no illegal activity or paraphernalia and evening curfew)
*
Yes
No
Medication
Diagnosis
Schooling details (i.e. what school do they attend, what hours and for how many days per week)
Has the YP attended STEPS?
Has the YP attended CAMHS? If so, provide details of in what capacity
Has the YP attended any juvenile incarceration facilities? If so, provide details of when, what for and for how long
Self-harm / suicidal ideation concerns or history
Current court orders
What family support is currently available?
Does the Young Person identify as Aboriginal or Torres Strait Islander?
Aboriginal
Torres Strait Islander
Both Aboriginal and Torres Strait Islander
No
Prefer not to say
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About the Referral
Description of why the young person wants to access SACY house
*
Overview of current situation
*
Significant life events
Emergency Exit Plan
NB: SaCY Program Management will contact the referrer within two business days to discuss ongoing support.
Emergency Exit Plan — Primary contact in case of an emergency (name, relationship, phone)
*
Emergency Exit Plan — Alternative accommodation
*
Emergency Exit Plan — Responsible people and contact numbers
Phone Number
-
Area Code
Phone Number
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Risk Domains
Please score the 5 domains below with 1 being low risk and 5 being high risk or concern.
Risk to Self — Score
*
Please Select
0
1
2
3
4
5
Consider: suicidal ideation; self-harm or impulsivity; high-risk behaviour; acute mental distress; distress levels and coping strategies; alcohol or other drug (AOD) use.
Risk to Self — Details
Risk to Others — Score
*
Please Select
0
1
2
3
4
5
Consider: aggression or threats; violent ideation or psychosis; poor impulse control; history of violence or intimidation.
Risk to Others — Details
Emotional & Cognitive Capacity — Score
*
Please Select
0
1
2
3
4
5
Consider: expressed emotions (e.g. loneliness, homesickness); capacity for flexible thinking; hopelessness, distress, eating habits; ability to self-regulate.
Emotional & Cognitive Capacity — Details
Functional Diversity — Score
*
Please Select
0
1
2
3
4
5
Consider: neurodiversity needs; physical or cognitive limitations; self-care and hygiene knowledge; service accessibility or health barriers.
Functional Diversity — Details
Support & Engagement — Score
*
Please Select
0
1
2
3
4
5
Limited or absent support network (family, community, services). Low engagement or unwillingness to engage with supports. Few or no protective factors present.
Support & Engagement — Details
Submit Referral
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