02 9722 5200

Case Work Referral Form

Case Work Referral Form

Details of Child/Young Person (0-18 years)

Interpreter Required
Do you identify as Aboriginal or Torres Islander?
Residential Status

Details of Other Children Requiring Support

Details of Parent/Caregiver of Child/Young Person

Interpreter Required

Referrer Details (if applicable)

Is the child/young person/family aware of this referral?
Please provide as much information as possible (e.g. psychological/emotional/behavioural/physical/social problems, learning difficulties, development issues, play or peer issues, family difficulties, parenting/attachment issues and/or other.
Are there any access issues
Are there any current child protection concerns?
If yes, please phone the Child Protection Helpline 13 12 11
Are there any current Domestic Violence concerns?
If yes, please phone the Domestic Violence Line 1800 656 463
Are there any current Family Law Court matters?
If yes, more information may be required.

Risk Assessment

Risk of harm to self
Current Plan or Intent - please refer to the Mental Health Access Line on 1800 011 511 or 000
Risk of harm to others
Current Plan or Intent - please refer to the Mental Health Access Line on 1800 011 511 or 000


  • Client agrees to their information being shared with Woodville Alliance for the purpose of determining eligibility to the program
  • Client understands that they will be contacted by the allocated Woodville Alliance Case Worker to arrange an assessment
  • Client agrees to their deidentifed data being shared for administrative and project evaluation purposes
  • Client understands that they may be contacted by Woodville Alliance or its representative to complete a client experience of care survey
Client understands and agrees to the above referral.
Referrer confirms that consent has been given for this referral to proceed.
Please note that the referral cannot proceed without consent given.
Parent/Guardian has authority to give consent?
How did you hear about Woodville Alliance?