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 include details of the referrer if not from an OOHC provider.	Be in OOHC or have a history of OOHC Aged 16-21 years Referred by: Medical Professional – details: Educational Institution – details: Other service provider – details:
Are you receiving support from another Veritas House service?	SHS £ HYAP £ TFS £ TI-IPS£ SILS £ PSP £ CCS £ Details:
Eligibility for YI
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:
☐ YI	☐ 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: