Section 1: General Information

Date of referral
Referring Unit (CSC/FSP)
Caseworker Name	Manager Name
Details of young person
Name of young person	Preferred name
Date of birth	Gender
Aboriginal or Torres Strait Islander	Yes No
Cultural background
Current Residency Status	Australian Citizen Permanent Resident Other
Religion
Referral Details
Is the YP aware of the referral?	Yes No
Has YP provided consent?	Yes No Is this consent: Verbal Written (Please Attach)
If under 18 years who is the holder of Parental Responsibility? Please note: Consent from the person being referred is required to complete this referral.	Name: Relationship: Address: Phone:
Eligibility: Please select the most applicable. If selecting number 5, please skip section 2.	New placement within the last 12 months Leaving care from Residential Care Early School Leaver (not currently attending any education institution) Leaving Care from an institution (including justice centre) or refuge
Are you receiving support from another Veritas House service?	SHS HYAP TEI SILS PSP CCS Details:
Eligibility for PYI
Age	17 years old Older Please specify age:
Level of independence	Independent Living Skills Checklist completed? Yes No
Bank Account? Yes No
Birth Certificate? Yes No
Tax File Number? Yes No
Drivers Licence/ NSW Photo ID Yes Type: No
Medicare Card: Yes No
Centrelink Payment? Yes No If yes, what payments?
Views of young person about living independently and their future goals
Birth family and other people significant to young person
Mother’s name
Address & Phone number
Father’s name
Address & Phone number
Sibling’s name	Date of birth	Legal status	Location (suburb/town) If OOHC, who provides case management?
Extended family/significant others
Name	Relationship to young person	Address & Phone number
Do you provide consent for a third party to communicate on your behalf?	Yes No If yes, please provide full name and phone number:

Section 2: Statutory Care/ Permanency Support

H

CAT	Low Needs Medium Needs High Needs ☐	Date completed?
In Statutory OOHC?	Yes No
History of DCJ involvement
When did the young person first enter OOHC?
Date of final orders?
Brief outline of reasons for entry into care
Brief placement history
Period	Placement type / Carer details / Location
Contact Arrangements
The young person has the following contact arrangement
Name	Relationship to young person?	Address & Phone number	Arrangements (Frequency/ Duration/ Activities/ Supervised)

Section 3: Safety

Immediate Safety Concerns: Please note: Safety concerns and risks identified in Section 3 require a risk management plan to be completed by a Veritas House staff member	Yes No If yes, address concerns:
Risks to the person:	Has a risk management plan been completed? Yes No
☐ Domestic or family violence ☐ Unaccompanied under 16-year-old (HYAP) ☐ Threats, violence or harassment ☐ Risk to accompanying children ☐ Suicidal thoughts/self-harm ☐ Parental Responsibility of the Minister ☐ Physical health ☐ Disability ☐ Mental health ☐ Other Details:
Risks the person poses to others:
☐ Domestic or family violence ☐ Mental Health ☐ Threats, violence or harassment ☐ Risks to children and / or young people ☐ Physical health ☐ Other Details:
Urgent Safety Issues that require immediate response:	Yes No Details:
Locational Restrictions relating to where the young person can be placed?	Bail or parole conditions ☐ Legal or AVO requirements ☐ Domestic or Family Violence ☐ Other (please specify):
Identified Issues:
☐ Challenging behaviours ☐ Child Protection ☐ Counselling / support ☐ Cultural/religious ☐ Disability ☐ Domestic & family violence ☐ Drug & Alcohol use ☐ Education ☐ Employment ☐ Relationship breakdown ☐ Food / meals ☐ Gender Identity ☐ Identity papers ☐ Legal ☐ Literacy ☐ Living skills ☐ Medical / general health services ☐ Mental health services ☐ Non-family violence ☐ NDIS ☐ Parenting / caring ☐ Personal safety & wellbeing ☐ Psychological trauma ☐ Finances & money management ☐ Sexual health ☐ Tenancy support ☐ General health / wellbeing / self-care ☐ Income support/gov allowance ☐ Transition from care arrangement ☐ Transition from custodial arrangements ☐ Other Provide details of issues identified:

Section 4: Accommodation:

Current Homelessness Status	At risk of homelessness Homeless Is not homeless or currently at risk but may be on exit from care
History of Homelessness	Yes No ☐ 1 week to 1 month ago ☐ More than 1 to 6 months ago ☐ More than 6 months to 1 year ago ☐ More than 1 year to 5 years ago ☐ More than 5 years ago ☐ Don’t know
Young Person has applied for Social Housing:	No Yes T-number:
Person’s Current Accommodation: (Include details of where person was last week and 12 months ago)	☐ Private house / town house / flat ☐ Boarding / rooming house ☐ Social housing: Public housing / Community housing / Aboriginal Community Housing / Aboriginal Housing Office ☐ Emergency accommodation ☐ Hotel / motel / bed & breakfast ☐ Couch surfing ☐ Hospital (excluding psychiatric) ☐ Young people in statutory care arrangements (SIL, ITC, PSP) ☐ Psychiatric hospital / unit ☐ Caravan ☐ Disability Support ☐ Tent ☐ Rehabilitation ☐ Cabin ☐ Adult correctional facility ☐ Boat ☐ Youth justice correctional facility ☐ Improvised dwelling ☐ Boarding school / residential college ☐ Motor vehicle ☐ Immigration detention centre Details:
Date person must leave this current accommodation:

Section 5: Other

Education/Training
Name of School/TAFE
Year/Course Details including attendance schedule & support needs
Contact person & Phone number
Employment
Currently Employed	No Yes Type: Full-time Part-time Casual

Health
Medicare Card Number
Health Care Card Number
Treating practitioners who see the child or young person regularly are:
Name	Address	Phone
General practitioner
Paediatrician
Psychologist
Psychiatrist
Dentist
Other
Supporting Documentation
The following documents are attached to this referral form
Required Items
Child Assessment Tool (CAT)	Yes	No	Birth Certificate	Yes	No
Client Information Form (CIF A & B)	Yes	No	Current Case Plan	Yes	No
Court Order (Minute of Care Order)	Yes	No	Independent Living Skills Checklist	Yes	No
Documents RE: JJ involvement, bail conditions, AVOs (if applicable)	Yes	No	Behaviour Support Plan (if applicable)	Yes	No

Office use only
Outcome of referral:	Date:	Staff member:
☐ PYI	☐ Risk Management plan completed	☐ Management consulted	☐ Referral accepted
☐ Wait listed
☐ Did not meet criteria	☐ Person declined service	☐ Risk level	☐ No vacancy
☐ Referrer has been informed of out come	☐ Referrer has been provided details for appropriate services
☐ Referred to appropriate service	Provide details:
Follow up required:	☐ No	☐ Yes provide details:
Staff member signature:	Manager’s signature: