Enquiries & Referrals

Has the Client or legal Guardian consented to this referral?* - required

Yes No

young person aware

Is the young person aware of this referral?* - required

Yes No

Please Note

Referral Criteria

If you do not have consent, do not proceed - please contact the Worker on Duty at either High Street Youth Health Service (8860 2500) or Western Area Adolescent Team (9881 1230) to discuss prior to making a referral.

NOTE TO REFERRER: Youth Health is not a crisis service. If the young person is experiencing high levels of distress which may result in harm to themselves or others, please refer them directly to your local hospital Emergency Department or 000 in emergencies. Service providers, clients or carers can also contact the NSW mental health line [1800 011 511].

Referrer Information

Information about the Individual completing this form

Which service is this referral for?* - required

Contact Name* - required

Position/Relationship* - required

Organisation (if applicable)

Address

Suburb

Post Code

Postal Address (if different from above)

Contact Number* - required

Fax

Date* - required

Reason for Referral

Brief description of current situation and requirements for young person* - required

This information is essential for Youth Health to assess this request. Please provide a summary of the child or young persons current situation, your concerns and what support they are seeking from Youth Health.

What service do you feel the young person requires? (select as many services as required)* - required

Counselling (for young people 12-20yrs) A Youth Health Assessment Nursing/Medical Assessment clinic (includes brief nursing support for young women who are pregnant and not yet engaged with antenatal care, or young parents who are at risk and not engaged with mainstream health services) Service Tour Health Care Coordination Legal Aid NSW Clinic (please call 8860 2500 to discuss eligibility and appointment booking. This is an outreach clinic provided by NSW Legal Aid (civil law matters ONLY)

Information about Young Person being referred

The following identifying client information is essential to refer a client

Given names* - required

Surname* - required

Preferred name* - required

Date of Birth* - required

Current age* - required

Gender* - required

Male Female Non-binary Prefer not to say Other

Gender Other

Address

Suburb

Post Code

Contact Number

Medicare card number and expiry date

Health Care card number and expiry date

Please note if the patient does not have a Medicare card

Does your patient identify as

ATSI CALD

Country of birth* - required

Languages spoken* - required

Religion* - required

Occupation* - required

Are you a student?

Yes No

Please provide contact details of an emergency contact person

(this is essential for children 15 years or younger)

Given names* - required

Surname

Relationship to client* - required

Next of kin* - required

Yes No

Agreeable to contact?* - required

Yes No

Home / Work Contact Number* - required

Does the young person have a regular General Practitioner or treating Doctor

Does the young person have a regular General Practitioner or treating Doctor?* - required

Yes No

General Practitioner or treating Doctor

GP/Doctor Name* - required

Address* - required

Suburb* - required

Postcode* - required

Contact Number* - required

Are there any other support services involved with the child / young person

Are there any other support services involved with the child / young person?

Yes No

Other support services involved with the child

Please provide the name of the organisation/s and their support role (including your own organisation)* - required

Does the young person have a preferred gender of staff

Does the young person have a preferred gender of staff?

Yes No Don't know

Preferred staff gender

Preferred staff gender* - required

Male preferred Female preferred

Triage Information

(Please provide information relevant to the referral you are making, if you do not have the information please mark as NK)

Living situation/Accommodation (where does the young person live, who with, how long, is it safe/stable)

Education/Work/Income (Do they go to school, do they work, income source)

Activities (what do they do for fun, what sort of things fill up their day e.g. sports, exercise, internet, etc.?)

Drug and Alcohol Use (Does young person use any drugs or alcohol, regularly, recreationally or socially, including tobacco/cigarettes)

Sexuality and relationships (ie: who are the significant relationships in young person’s life, does the young person require support in regards to their gender or sexuality? Is the young person at risk of unplanned pregnancy or sexually transmitted infections?)

Mental health (in the last 2 weeks has young person felt distressed/sad/anxious more than usual, have they harmed themselves in the last 3 months or had thoughts of self-harm)

Has there been any current or past involvement with mental health Services?

Yes No

Safety (does the young person see their accommodation as safe, have they been injured /attacked / assaulted in the last 3 months)

Health / Physical Health (Any current or past health concerns, past medical history, medication, chronic condition, recent injury, vaccinations, general health issues)

Do you have any additional information or concerns?

What's next?

If you have any queries or require assistance completing this referral, please contact the Worker on Duty at your nearest youth health service.
Once received, a youth health staff member will attempt to contact the young person / you within 2 business days.

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Enquiries & Referrals

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