Case Work Referral Form Case Work Referral Form Details of Child/Young Person (0-18 years) First Name * Family Name * Date of Birth * Gender Male Female Intersex Indeterminate Address * Phone Email * Country of Birth Cultural Background Preferred Language Interpreter Required Yes No Do you identify as Aboriginal or Torres Islander? Yes No Wish not to state Residential Status Citizen Permanent Resident Asylum Seeker Indeterminate Refugee Visa Status Details of Other Children Requiring Support Name Date of Birth Name Date of Birth Name Date of Birth Details of Parent/Caregiver of Child/Young Person First Name Family Name Relationship to Child/Young Person Gender Male Female Intersex Indeterminate Address Phone Email * Preferred Language Interpreter Required Yes No Date Referrer Details (if applicable) First Name Family Name Position Organisation Phone Email Is the child/young person/family aware of this referral? Yes No Description of Presenting Concerns 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. What other services are working with the child, young person and the family? What is the child/young person/family’s goal/reason for requesting this service? Is there a mental health diagnosis? Are there any access issues Mobility Hearing Sight Communication Other(please specify)Other(please specify) Are there any current child protection concerns? No Yes If yes, please phone the Child Protection Helpline 13 12 11 Are there any current Domestic Violence concerns? No Yes If yes, please phone the Domestic Violence Line 1800 656 463 Are there any current Family Law Court matters? No Yes If yes, more information may be required. Risk Assessment Risk of harm to self No Yes Current Plan or Intent - please refer to the Mental Health Access Line on 1800 011 511 or 000 Risk of harm to others No Yes Current Plan or Intent - please refer to the Mental Health Access Line on 1800 011 511 or 000 Consent 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. * Client understands and agrees to the above referral. Referrer confirms that consent has been given for this referral to proceed. * 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? * No Yes Date How did you hear about Woodville Alliance? Family/Friends School Social Media (Facebook/ Twitter/Instagram) Website Other(please specify)Other(please specify) Paragraph Submit
