Client Referral

GET REFERRED &

COME SEE US TODAY

OUR TYPES OF REFERRALS

Eleanor Duncan Aboriginal Services’ highly trained, professional staff has been providing health care to Aboriginal and Torres Strait Islander people on the Central Coast for more than 20 years.

Eleanor Duncan provides comprehensive primary care to patients, including:

NDIS REFERRAL

National Disability Insurance Scheme (NDIS) Referral

YADHABADHIWA AOD DAY REHAB SELF REFERRAL

For Aboriginal Parents with Dependent Aboriginal children who live on Darkinjung Country

YADHABADHIWA AOD DAY REHAB AGENCY REFERRAL

For Aboriginal Cares with Dependent Aboriginal children who live on Darkinjung Country

BURIDJGA REFERRAL

Buridjga Youth Services Referral (12 to 24 years)

NDIS REFERRAL

National Disability Insurance Scheme (NDIS) Referral

CLIENT'S FIRST NAME

CLIENT'S LAST NAME

CLIENT DOB

CLIENT PHONE

CLIENT GENDER

IS THE CLIENT?

ABORIGINAL TORRES STRAIT ISLANDER NON-ABORIGINAL

CLIENT ADDRESS

IS THE ADDRESS PERMANENT OR TEMPORARY?

REFERRER ORGANISATION NAME

REFERRER CONTACT NAME

REFERRER PHONE

REFERRER EMAIL

IS THE CLIENT AWARE OF THE REFERRAL?

YES NO

HAS CONSENT BEEN OBTAINED FOR THE REFERRAL?

YES NO

PARENT / GUARDIAN CARER FULL NAME

PARENT / GUARDIAN CARER PHONE

PARENT / GUARDIAN CARER EMAIL

RELATIONSHIP TO CLIENT

NAME OF CLIENT'S SCHOOL

CLIENT'S SCHOOL YEAR

WHAT ASSISTANCE DOES THE CLIENT REQUIRE?

SUPPORT COORDINATION RESPITE (7-65 YEARS) SPECIALISED SUBSTITUTE RESIDENTIAL CARE (SSRC) NDIS ACCESS ELIGIBILITY SUPPORT

CLIENT GP PRACTICE NAME

CLIENT GP FULL NAME

CLIENT GP PHONE

HAS THE CLIENT HAD A 715 ABORIGINAL AND TORRES STRAIT ISLANDER HEALTH CHECK WITHIN THE PREVIOUS 12 MONTHS?

YES NO UNSURE

IS THE CLIENT CURRENTLY ON MEDICATION?

YES NO UNSURE

ARE THERE ANY BARRIERS THE CLIENT FACES IN ACCESSING THESE SERVICES?

YES NO

IF SO, PLEASE EXPLAIN?

ARE THERE ANY CURRENT/PREVIOUS APPREHENDED DOMESTIC VIOLENCE ORDERS (AVO) AGAINST THE CLIENT?

YES NO

HAS THE CLIENT RECENTLY BEEN RELEASED FROM GAOL?

YES NO

DOES THE CLIENT HAVE ANY COURT MATTERS COMING UP?

YES NO UNSURE

IS THE CLIENT CURRENTLY ON BAIL CONDITIONS AND LINKED WITH CORRECTIONS OR PROBATION AND PAROLE?

YES NO UNSURE

HAS THE CLIENT DISPLAYED ANY VIOLENT OR AGGRESSIVE BEHAVIOUR?

YES NO UNSURE

ON A SCALE FROM 0-10 (0 BEING LOWEST, 10 BEING HIGHEST), PLEASE IDICATE THE AMOUNT OF RISK YOU CONSIDER FOR SUICIDE RISK

0 1 2 3 4 5 6 7 8 9 10

ON A SCALE FROM 0-10, PLEASE IDICATE THE AMOUNT OF RISK YOU CONSIDER FOR DELIBERATE SELF-HARM

0 1 2 3 4 5 6 7 8 9 10

ON A SCALE FROM 0-10, PLEASE IDICATE THE AMOUNT OF RISK YOU CONSIDER FOR SEXUAL/ PHYSICAL ABUSE

0 1 2 3 4 5 6 7 8 9 10

ON A SCALE FROM 0-10, PLEASE IDICATE THE AMOUNT OF RISK YOU CONSIDER FOR CHILD PROTECTION

0 1 2 3 4 5 6 7 8 9 10

ON A SCALE FROM 0-10, PLEASE IDICATE THE AMOUNT OF RISK YOU CONSIDER FOR FAMILY BREAKDOWN

0 1 2 3 4 5 6 7 8 9 10

PLEASE PROVIDE ANY FURTHER DETAILS REGARDING RISK ISSUES FACED BY THE CLIENT:

HAS THE CLIENT BEEN ADMITTED TO A DETOX UNIT OR REHABILITATION FACILITY?

YES NO

DOES THE CLIENT USE ALCOHOL OR OTHER DRUGS (PRESCRIBED OR DRUGS OF CHOICE)?

ALCOHOL OTHER DRUGS (PRESCRIBED) OTHER DRUGS (DRUGS OF CHOICE) BOTH NEITHER

PLEASE PROVIDE DETAILS OF SUPPORT NETWORK, FAMILY OR OTHER WORKERS SUPPORTING THE CLIENT:

ITC CHRONIC DISEASE REFERRAL

ITC Chronic Disease Referral

CLIENT'S FIRST NAME

CLIENT'S LAST NAME

CLIENT DOB

CLIENT PHONE

CLIENT GENDER

IS THE CLIENT:

ABORIGINAL TORRES STRAIT ISLANDER NON-ABORIGINAL

CLIENT ADDRESS

REFERRER ORGANISATION NAME

REFERRER NAME

REFERRER PHONE

REFERRER EMAIL

IS THE CLIENT AWARE OF THE REFERRAL?

YES NO

HAS CONSENT BEEN OBTAINED FOR THE REFERRAL?

YES NO

WHICH CHRONIC CONDITION/S DOES THE CLIENT HAVE?

DIABETES CHRONIC RESPIRATORY DISEASE CANCER CARDIOVASCULAR DISEASE CHRONIC KIDNEY DISEASE

WHAT CARE ASSISTANCE DOES THE CLIENT REQUIRE?

CARE COORDINATION SUPPLEMENTARY - TRANSPORT SUPPORT SUPPLEMENTARY - SPECIALIST SUPPORT SUPPLEMENTARY - ALLIED HEALTH SUPPORT SUPPLEMENTARY - MEDICIAL AID SUPPORT SUPPLEMENTARY - NUTRITIONAL SUPPLEMENTS

CLIENT GP NAME

CLIENT GP PRACTICE NAME

CLIENT GP PHONE

IS THE CLIENT REGISTERED FOR CLOSING THE GAP (CTG)?

YES NO UNSURE

HAS THE CLIENT HAD A 715 ABORIGINAL AND TORRES STRAIT ISLANDER HEALTH CHECK WITHIN THE PREVIOUS 12 MONTHS?

YES NO UNSURE

HAS THE CLIENT HAD A GENERAL PRACTITIONER MANAGEMENT PLAN?

YES NO UNSURE

OTHER RELEVANT INFORMATION INCLUDING CLIENT BARRIERS TO ACCESSING HEALTH SERVICES AND ASSOCIATED HEALTH RISKS:

A CURRENT GENERAL PRACTITIONER MANAGEMENT PLAN MUST BE ATTACHED AND UPLOADED WITH THIS REFERRAL FORM.

DHANGGAN GUDJAGANG REFERRAL

Mother & Baby Referral

IS THE PRIMARY CARER:

PRIMARY CARER'S / PARENTS FULL NAME

PRIMARY CARER / PARENT DOB

PRIMARY CARER / PARENT RELATIONSHIP STATUS

PRIMARY CARERS / PARENTS PHONE

BEST TIME TO PHONE?

PRIMARY CARER / PARENTS ADDRESS

IS THE ADDRESS PERMANENT OR TEMPORARY?

PRIMARY CARER / PARENT GENDER

CLIENTS CHILDREN NAME(S) (ONE NAME PER LINE FOR EACH SECTION BELOW AS WELL)

CLIENTS CHILDREN DATE OF BIRTH(S) OR EXPECTED DUE DATE

CLIENTS CHILDREN GENDER(S)

CLIENTS CHILDREN EDUCATION PROVIDER(S)

CLIENTS CHILDREN BEHAVIOUR ISSUES OR CONCERNS

REFERRAL MADE BY

REFERRER RELATIONSHIP TO CLIENT

REFERRER ORGANISATION NAME

REFERRER CONTACT NAME

REFERRER PHONE

REFERRER EMAIL

IS THE CLIENT AWARE OF THE REFERRAL?

YES NO

HAS CONSENT BEEN OBTAINED FOR THE REFERRAL?

YES NO

WHAT ASSISTANCE DOES THE CLIENT REQUIRE? (Please only select services which are required)

Social groups (e.g. women’s group or men’s group) Parents and family support groups Antenatal care Postnatal care Early childhood education and care Domestic and family violence support Parenting skills Cultural connection and support Care coordination

CLIENT GP FULL NAME (IF NOT A PATIENT OF YERIN)

CLIENT GP PRACTICE NAME

CLIENT GP PHONE

HAS THE CLIENT HAD A 715 ABORIGINAL AND TORRES STRAIT ISLANDER HEALTH CHECK IN THE LAST 9 MONTHS?

YES NO UNSURE

IS THE CLIENT CURRENTLY ON MEDICATION?

YES NO UNSURE

ARE THERE ANY BARRIERS THE CLIENT FACES IN ACCESSING THESE SERVICES?

YES NO

ARE THERE ANY CURRENT/PREVIOUS APPREHENDED DOMESTIC VIOLENCE ORDERS (AVO) INVOLVING THE CLIENT?

YES NO

IS THE CLIENT CURRENTLY ON BAIL CONDITIONS AND LINKED WITH CORRECTIONS OR PROBATION AND PAROLE?

YES NO

HAS THE CLIENT RECENTLY BEEN RELEASE FROM GAOL?

YES NO

DOES THE CLIENT HAVE ANY COURT MATTERS COMING UP?

YES, FAMILY COURT YES, CRIMINAL COURT NO

PLEASE PROVIDE DETAILS OF SUPPORT NETWORK, FAMILY OR OTHER WORKERS OR SERVICES SUPPORTING THE CLIENT.

PLEASE PROVIDE ANY ADDITIONAL INFORMATION YOU FEEL IS RELEVANT TO THIS REFERRAL.

YADHABA REFERRAL

Wellbeing Services Referral (18 years and over)

CLIENT'S FIRST NAME

CLIENT'S LAST NAME

CLIENT DOB

CLIENT GENDER

IS THE CLIENT?

ABORIGINAL TORRES STRAIT ISLANDER NON-ABORIGINAL

CLIENT PHONE

CLIENT ADDRESS

IS THE ADDRESS PERMANENT OR TEMPORARY?

DOES THE CLIENT HAVE A VALID MEDICARE CARD?

YES NO

REFERRER ORGANISATION NAME

REFERRER CONTACT NAME

REFERRER PHONE

REFERRER EMAIL

IS THE CLIENT AWARE OF THE REFERRAL?

YES NO

HAS CONSENT BEEN OBTAINED FOR THE REFERRAL?

YES NO

WHAT ASSISTANCE DOES THE CLIENT REQUIRE?

ADVICE AND REFERRAL CASE MANAGEMENT ASSISTANCE WITH ACCESSING DETOX AND REHABILITATION PSYCHOLOGY/ COUNSELING

WHAT ADDITIONAL SUPPORT WOULD YOUR CLIENT BENEFIT FROM?

MEN'S GROUP WOMEN'S GROUP YADHABA WELLBEING GROUP ALCOHOLICS ANONYMOUS NARCOTICS ANONYMOUS GAMBLERS ANONYMOUS

CLIENT GP PRACTICE NAME

CLIENT GP FULL NAME (IF NOT A PATIENT OF YERIN)

CLIENT GP PHONE

HAS THE CLIENT HAD AN ANNUAL HEALTH CHECK (715)?

YES NO UNSURE

DOES THE CLIENT HAVE A FORMAL DIAGNOSIS? IF YES, PLEASE INCLUDE DIAGNOSIS.

IS THE CLIENT CURRENTLY ON MEDICATION? IF SO, PLEASE INCLUDE DETAILS.

DOES THE CLIENT HAVE A MENTAL HEALTH TREATMENT PLAN? IF YES, PLEASE EMAIL TO INTAKE@YERIN.ORG.AU

ARE THERE ANY CURRENT/PREVIOUS APPREHENDED DOMESTIC VIOLENCE ORDERS (AVO) AGAINST THE CLIENT?

YES NO

HAS THE CLIENT RECENTLY BEEN RELEASED FROM GAOL?

YES NO

DOES THE CLIENT HAVE ANY COURT MATTERS COMING UP?

YES NO UNSURE

IS THE CLIENT CURRENTLY ON BAIL CONDITIONS AND LINKED WITH CORRECTIONS OR PROBATION AND PAROLE?

YES NO UNSURE

HAS THE CLIENT DISPLAYED ANY VIOLENT OR AGGRESSIVE BEHAVIOUR?

YES NO UNSURE

ARE YOU EXPERIENCING ANY OF THE FOLLOWING:

DEBT FINES FAMILY LAW ISSUES CONSUMER ISSUES DISCRIMINATION HASRASSMENT PROBLEMS IN THE WORKPLACE PROBLEMS WITH YOUR NEIGHBOUR/S ISSUES WITH THE POLICE OR OTHER GOVERNMENT ORGANISATIONS COURT MATTERS VICTIM OF VIOLENCE NONE OF THE ABOVE

HAVE YOU HAD OR DO YOU HAVE SUICIDAL THOUGHTS? IF YES, DO YOU HAVE A CURRENT PLAN?

ON A SCALE FROM 1-5, IN THE LAST FOUR WEEK,S ABOUT HOW OFTEN DID YOU FEEL NERVOUS?

1 2 3 4 5

ON A SCALE FROM 1-5, IN THE LAST FOUR WEEKS, ABOUT HOW OFTEN DID YOU FEEL WITHOUT HOPE?

1 2 3 4 5

ON A SCALE FROM 1-5, IN THE LAST FOUR WEEKS, ABOUT HOW OFTEN DID YOU FEEL RESTLESS OR JUMPY?

1 2 3 4 5

ON A SCALE FROM 1-5, IN THE LAST FOUR WEEKS, ABOUT HOW OFTEN DID YOU FEEL EVERYTHING WAS AN EFFORT?

1 2 3 4 5

ON A SCALE FROM 1-5, IN THE LAST FOUR WEEKS, ABOUT HOW OFTEN DID FEEL SO SAD THAT NOTHING COULD CHEER YOU UP?

1 2 3 4 5

DOES THE CLIENT HAVE ISSUES WITH TRANSPORT?

YES NO UNSURE

IS THE CLIENT CURRENTLY ATTENDING A DETOX OR REHABILITATION FACILITY? IF YES, WHICH FACILITY?

DOES THE CLIENT USE ALCOHOL OR OTHER DRUGS (PRESCRIBED OR DRUGS OF CHOICE)?

ALCOHOL OTHER DRUGS (PRESCRIBED) CANNABIS OPIOIDS STIMULANTS NEITHER

PLEASE PROVIDE DETAILS OF SUPPORT NETWORK, FAMILY OR OTHER WORKERS SUPPORTING THE CLIENT:

SELF-REFERRAL YADHABADHIWA AOD DAY REHAB

For Aboriginal Parents with Dependent Children

DO YOU HAVE DEPENDENT CHILDREN/GRANDCHILDREN?

YES NO

HOW MANY? (IF YOU RESPONDED YES IN THE PREVIOUS QUESTION)

Please use the Yadhaba Referral form instead.

DEPENDENT AGES

0 - 5 5 - 10 10 - 16

CLIENT'S FIRST NAME

CLIENT'S LAST NAME

CLIENT DOB

CLIENT GENDER

CLIENT PHONE

IS THE CLIENT?

ABORIGINAL TORRES STRAIT ISLANDER NON-ABORIGINAL

CONTACT EMAIL

CLIENT ADDRESS

IS THE ADDRESS PERMANENT OR TEMPORARY?

WHAT ADDITIONAL SUPPORT WOULD YOUR CLIENT BENEFIT FROM?

MEN'S GROUP WOMEN'S GROUP YADHABA WELLBEING GROUP ALCOHOLICS ANONYMOUS NARCOTICS ANONYMOUS GAMBLERS ANONYMOUS

ARE THERE ANY CURRENT/PREVIOUS APPREHENDED DOMESTIC VIOLENCE ORDERS (AVO) AGAINST YOU?

YES NO

HAVE YOU RECENTLY BEEN RELEASED FROM GAOL?

YES NO

DO YOU HAVE ANY COURT MATTERS COMING UP?

YES NO UNSURE

ARE YOU CURRENTLY ON BAIL CONDITIONS AND LINKED WITH CORRECTIONS OR PROBATION AND PAROLE?

YES NO UNSURE

DO YOU HAVE ANY VIOLENT OR AGGRESSIVE BEHAVIOUR?

YES NO UNSURE

ARE YOU EXPERIENCING ANY OF THE FOLLOWING:

DEBT FINES FAMILY LAW ISSUES CONSUMER ISSUES DISCRIMINATION HARASSMENT PROBLEMS IN THE WORKPLACE PROBLEMS WITH YOUR NEIGHBOUR/S ISSUES WITH THE POLICE OR OTHER GOVERNMENT ORGANISATIONS COURT MATTERS VICTIM OF VIOLENCE NONE OF THE ABOVE

In the last 6 months have you needed to drink or use drugs more to get the affects you want?

NO YES, A BIT MORE YES, A LOT MORE

When you have cut down or stopped drinking or using drugs in the past, have you experienced any symptoms, such as sweating, shaking, feeling sick in the tummy/vomiting, diarrhoea, feeling really down or worried, problems sleeping, aches and pains?

NEVER SOMETIMES WHEN I STOP YES, EVERY TIME

How often do you feel that you end up drinking or using drugs much more than you expected.

NEVER/HARDLY EVER ONCE A MONTH ONCE A FORTNIGHT ONCE A WEEK MORE THAN ONCE A WEEK MOST DAYS/EVERY DAY

Do you ever feel out of control with your drinking or drug use?

SOMETIMES OFTEN MOST DAYS / EVERY DAY

How difficult would it be to stop or cut down on your drinking or drug use?

NOT DIFFICULT AT ALL FAIRLY EASY DIFFICULT I COULDN'T STOP OR CUT DOWN

What time of the day do you usually start drinking or using drugs?

IN THE AFTERNOON SOMETIME IN THE MORNING AS SOON AS I WAKE UP

How often do you find that your whole day has involved drinking or using drugs?

NEVER/HARDLY EVER SOMETIMES OFTEN MOST DAYS/EVERY DAY

How often do you feel down in the dumps, sad or slack?

NEVER/HARDLY EVER SOMETIMES MOST DAYS/EVERY DAY

How often have you felt that life is hopeless?

NEVER/HARDLY EVER SOMETIMES MOST DAYS/EVERY DAY

How often do you feel nervous or scared?

NEVER/HARDLY EVER SOMETIMES MOST DAYS/EVERY DAY

Do you worry much?

NEVER/HARDLY EVER SOMETIMES MOST DAYS/EVERY DAY

How often do you feel restless and that you can’t sit still?

NEVER/HARDLY EVER SOMETIMES MOST DAYS/EVERY DAY

HAVE YOU HAD OR DO YOU HAVE SUICIDAL THOUGHTS?

YES NO

IF YES, DO YOU HAVE A CURRENT PLAN?

YES NO

**** IF YES SMS PLEASE CALL 000, LIFELINE 131114, 13YARN 139276****

AGENCY REFERRAL YADHABADHIWA AOD DAY REHAB

For Aboriginal Parents with Dependent Children

STAFF MEMBER NAME

STAFF MEMBER PHONE

STAFF MEMBER EMAIL

PROGRAM/SERVICE OF INTEREST

ORGANISATION NAME

ADDRESS

HOURS OF OPERATION

NAME OF PROGRAM

CONTACT NAME

PHONE

MOBILE

CLIENT CONSENT FOR REFERRAL

YES NO

REASON FOR REFERRAL

ISSUES IDENTIFIED BY REFERRING AGENCY

ANY RISKS?

Self-harm

High Medium Low

Suicidal

High Medium Low

To others

High Medium Low

CLIENT'S FIRST NAME

CLIENT'S LAST NAME

CLIENT'S ADDRESS

CLIENT'S DATE OF BIRTH

CLIENT'S PHONE

IS THE CLIENT?

ABORIGINAL TORRES STRAIT ISLANDER NON-ABORIGINAL

CLIENT LANGUAGE SPOKEN

INTERPRETER REQUIRED?

Yes No

CLIENT'S GENDER

Client emergency contact details

FULL NAME

RELATIONSHIP TO CLIENT

ADDRESS

PHONE

PREFERRED METHOD OF CONTACT

MAIL PHONE MOBILE EMAIL

CURRENT PERSONAL SITUATION

SUMMARY OF SERVICES AND TREATMENT

CLIENT LIVES

ALONE WITH FAMILY/CARER OTHER

PLEASE SPECIFY

BENEFITS

YES NO

IF SO, WHAT TYPE?

EDUCATION

SCHOOL UNIVERSITY TAFE OTHER

PLEASE SPECIFY

EMPLOYMENT

FULL-TIME PART-TIME CASUAL SEEKING EMPLOYMENT

FAMILY AND SOCIAL SUPPORT

HEALTH ISSUES

PHYSICAL

MENTAL HEALTH

MEDICATION

LIFESTYLE ACTIVITIES

LEGAL ISSUES

ALLIED HEALTH REFERRAL

Allied Health Referral

CLIENT'S FIRST NAME

CLIENT'S LAST NAME

CLIENT DOB

CLIENT PHONE

CLIENT ADDRESS

IS THE ADDRESS PERMANENT OR TEMPORARY?

IS THE CLIENT?

ABORIGINAL TORRES STRAIT ISLANDER NON-ABORIGINAL

REFERRER ORGANISATION NAME

REFERRER CONTACT NAME

REFERRER PHONE

REFERRER EMAIL

IS THE CLIENT AWARE OF THE REFERRAL?

YES NO

HAS CONSENT BEEN OBTAINED FOR THE REFERRAL?

YES NO

PARENT / GUARDIAN CARER FULL NAME

PARENT / GUARDIAN CARER PHONE

PARENT / GUARDIAN CARER EMAIL

RELATIONSHIP TO CLIENT

NAME OF CLIENT'S SCHOOL

CLIENT'S SCHOOL YEAR

WHAT ASSISTANCE DOES THE CLIENT REQUIRE?

SPEECH THERAPY OCCUPATIONAL THERAPY PSYCHOLOGY

PAYMENT FOR SERVICES WILL BE MADE VIA:

WHAT ARE THE DETAILS OF THE PLAN?

ARE THERE ANY BARRIERS THE CLIENT FACES IN ACCESSING THESE SERVICES?

YES NO

CLIENT GP PRACTICE NAME

CLIENT GP FULL NAME

CLIENT GP PHONE

HAS THE CLIENT HAD A 715 ABORIGINAL AND TORRES STRAIT ISLANDER HEALTH CHECK WITHIN THE PREVIOUS 12 MONTHS?

YES NO UNSURE

IS THE CLIENT CURRENTLY ON MEDICATION?

YES NO UNSURE

ARE THERE ANY BARRIERS THE CLIENT FACES IN ACCESSING THESE SERVICES?

YES NO

IF SO, PLEASE EXPLAIN?

ARE CHILD PROTECTION ORDERS CURRENTLY IN PLACE?

YES NO

NAME/ SERVICE OF ANY OTHER SUPPORT ORGANISATION INVOLVED:

IF OTHER SERVICES ARE BEING ACCESSED, PLEAE DETAIL THE NAME, AND CONTACT DETAILS OF THE CASEWORKER/KEY WORKER:

MALIGA REFERRAL

Safer Families program for families living in the 2256 or 2257 postcodes.

PARENT/CARER'S FIRST NAME

PARENT/CARER'S LAST NAME

PARENT/CARER DOB

PARENT/CARER GENDER

IS THE PARENT/CARER:

ABORIGINAL TORRES STRAIT ISLANDER NON-ABORIGINAL

PARENT/CARER PHONE

FAMILY ADDRESS

PARENT/CARER EMAIL ADDRESS

REFERRER ORGANISATION NAME

REFERRER CONTACT NAME

REFERRER PHONE

REFERRER EMAIL

IS THE PARENT/CARER AWARE OF THE REFERRAL?

YES NO

HAS CONSENT BEEN OBTAINED FOR THE REFERRAL?

YES NO

ARE THE CHILDREN ABORIGINAL AND OR TORRES STRAIT ISLANDER?

ABORIGINAL TORRES STRAIT ISLANDER BOTH NEITHER

WHAT ASSISTANCE DOES THE FAMILY REQUIRE?

ADVICE AND REFERRAL CASE COORDINATION SCHOOL ADVOCACY EDUCATIONAL SUPPORT PSYCHOLOGY/ COUNSELING

ADDITIONAL INFORMATION (OPTIONAL)

WHAT ADDITIONAL SUPPORT WOULD THE FAMILY BENEFIT FROM?

SOCIAL GROUPS (WOMEN'S, MEN'S AND WELLBEING GROUP) PARENTING AND FAMILY SUPPORT GROUPS DOMESTIC AND FAMILY VIOLENCE SUPPORT

ADDITIONAL INFORMATION (OPTIONAL)

HOW MANY CHILDREN ARE IN THE HOUSEHOLD?

WHAT TYPE OF SCHOOL DOES YOUR CHILD/CHILDREN ATTEND? Please select all that apply.

PRESCHOOL PRIMARY SECONDARY

WHAT ARE THE CHILDREN'S NAMES?

HOW OLD ARE THE CHILDREN?

PLEASE ADD THE CHILDREN'S DATE OF BIRTH

DOES THE FAMILY CURRENTLY ACCESS SUPPORT SERVICES?

YES NO

IF YES, PLEASE PROVIDE DETAILS OF THE SUPPORT SERVICES ACCESSED.

ARE THERE ANY BARRIERS THE FAMILY FACES IN ACCESSING SERVICES, IF SO, PLEASE EXPLAIN?

BURIDJGA REFERRAL

Buridjga Youth Services Referral (12 to 24 years)

CLIENT'S FIRST NAME

CLIENT'S LAST NAME

CLIENT DOB

CLIENT PHONE

CLIENT GENDER

IS THE CLIENT?

ABORIGINAL TORRES STRAIT ISLANDER NON-ABORIGINAL

CLIENT ADDRESS

PARENT/CARER NAME

PARENT/CARER PHONE NUMBER

PARENT/CARER EMAIL ADDRESS

DOES THE PARENT/CARER IDENTIFY AS:

ABORIGINAL TORRES STRAIT ISLANDER BOTH NEITHER

REFERRER ORGANISATION NAME

REFERRER CONTACT NAME

REFERRER PHONE

REFERRER EMAIL

IS THE CLIENT AWARE OF THE REFERRAL?

YES NO

HAS CONSENT BEEN OBTAINED FOR THE REFERRAL?

YES NO

NAME OF CLIENT'S SCHOOL

CLIENT'S SCHOOL YEAR

CLIENT'S SCHOOL ENGAGEMENT

ENGAGED AT RISK OF DISENGAGEMENT DISENGAGED

FOCUS OF SERVICE DELIVERY:

INTAKE AND ASSESSMENT FAMILY CAPACITY BUILDING PROVIDING INFORMATION, ADVICE, AND REFERRAL PATHWAYS PROVIDING EDUCATION AND SKILLS TRAINING ADVICE SPECIALIST SUPPORT ACCESS AND REFERRALS

PLEASE PROVIDE DETAILS OF ANY SERVICES OR SUPPORTS THE CLIENT IS CURRENTLY ACCESSING:

DOES THE CLIENT HAVE ANY BARRIERS THAT WOULD PREVENT THEM FROM ACCESSING SERVICES OR SUPPORTS?

PLEASE OUTLINE THE REASON FOR THIS REFERRAL.

DONATE

CLIENT REFERRAL

Client Referral

GET REFERRED &

COME SEE US TODAY

OUR TYPES OF REFERRALS

NDIS REFERRAL

YADHABA REFERRAL

YADHABADHIWA AOD DAY REHAB SELF REFERRAL

YADHABADHIWA AOD DAY REHAB AGENCY REFERRAL

GURAYI-BIYN YADHA REFERRAL

DHANGGAN GUDJAGANG REFERRAL

MALIGA REFERRAL

BURIDJGA REFERRAL

NDIS REFERRAL

ITC CHRONIC DISEASE REFERRAL

DHANGGAN GUDJAGANG REFERRAL

YADHABA REFERRAL

SELF-REFERRAL YADHABADHIWA AOD DAY REHAB

Please use the Yadhaba Referral form instead.

AGENCY REFERRAL YADHABADHIWA AOD DAY REHAB

ALLIED HEALTH REFERRAL

MALIGA REFERRAL

BURIDJGA REFERRAL

CONTACT US

8:30am - 5:00pm
(Monday - Friday)

(02) 4351 1040

3-5/56-64 Pacific Hwy, Wyong

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Get Assistance

Get Involved

About

Contact

Opening Hours

Client Referral

GET REFERRED &

COME SEE US TODAY

OUR TYPES OF REFERRALS

NDIS REFERRAL

ITC CHRONIC DISEASE REFERRAL

DHANGGAN GUDJAGANG REFERRAL

YADHABA REFERRAL

SELF-REFERRAL YADHABADHIWA AOD DAY REHAB

Please use the Yadhaba Referral form instead.

AGENCY REFERRAL YADHABADHIWA AOD DAY REHAB

ALLIED HEALTH REFERRAL

MALIGA REFERRAL

BURIDJGA REFERRAL

8:30am - 5:00pm (Monday - Friday)

3-5/56-64 Pacific Hwy, Wyong

8:30am - 5:00pm
(Monday - Friday)