Kingston Youth Services

Referral Form

Date of Referral:

Client details -

Name:

Age: 1213141516171819 / D.O.B. : / Gender: MaleFemale
Address: / Postcode:
School: Berendale SchoolCheltenham Secondary CollegeHeatherton Christian CollegeHolmesglen Institute of TAFEKilbreda Secondary CollegeMentone Girls' GrammarMentone Girls' Secondary CollegeMentone GrammarMordialloc Secondary CollegeParkdale Secondary CollegePatterson River Secondary CollegeSandringham Secondary CollegeSt. Bede's CollegeWestall Secondary College
Phone number (Home): / (Mobile):
Email address: / Cultural Background:

Emergency Contact –

Name:

Relationship to young person:

Contact Number:

Referral Source –

Name:

Contact details:

Has Parental Consent been obtained?

Would this young person have the capacity to attend the service in Southland out of school hours?

If yes, when would they be able to attend?:

Presenting Issues –

  • Reasons for presenting for support:

a)What are the current presenting issues?

b)What effects are the presenting issues having on the young person?

c)Why and How did the presenting issues arise?

d)What other supports does the client currently have (e.g. Friends, partner, school etc.)?

e)Is there anything else we may need to know to support the young person best?

Information for Support Services-

Has the client previously received counselling or support?

If so, with whom:

and when:

Does the young person see a GP for this issue?

If yes; GP Name:

Contact details:

Further Notes-

Following completion of this form please save to your hard drive (preferably under the student’s name) before attaching to an email and sending to mailto: double clicking on the email address (macros will need to be enabled).

Please read Youth Services Client Criteria Document (14/163338) below for further information on appropriate Youth Work referrals.

Any Questions please contact Youth Services on 1300 369 436 and discuss with the Duty Worker.

Kingston Youth Services Client Criteria

Youth Work

  • We work with young people aged 12-25 who live, work, study or play in City of Kingston.
  • We aim to ensure the interest of the young person we are working with comes first.
  • We work with young people to improve and support them in their relationships with their family, the community and society.
  • Youth workers also work with families, communities, schools, government decisions that affect the young person.
  • We play a facilitation role with young people not viewing them as passive recipients of service. This includes advocacy to influence decisions by others that impact young people’s lives as well as advocacy and facilitation of empowerment, independence and participation.
  • We connect young people to others around them (family, community, peer groups, society).
  • We aim to protect and facilitate the rights of young people.

Who we work with: Complexity, severity, criteria.

Youth Work: 3 – 6 months.

  • Tier 1 As per safe minds system of care map (Vic).
  • First place young people turn to for help - Provide first line response.
  • Severity: Intermittent pattern of distress in specific settings.
  • Complexity: Intermittent emotional distress in response to one or more life events or settings (e.g. parental separation, bullying, negative relationship, experimenting with risk taking behaviours)
  • Impact: Some impact to functioning but managing well.
  • Risk of Harm: Fleeting thoughts of self harm or aggression. Experimentation with illicit drugs or alcohol.
  • Risk Factors: None to a few significant risk factors that sometimes negatively influence functioning / cause emotional distress.

We are not or do not take on clients who:

  • Require specific expertise and skills in young peoples mental health.
  • Requires specialist mental health services
  • Have complex and severe mental health problems
  • Who are at high risk of harm.
  • Severity: Frequent emotional distress, significant behavior changes in area of usual functioning, (e.g. inconsistent attendance, changes in academic results) prolonged for four weeks or more. Or persistent / ongoing distress without clear trigger. Difficult to resolve distress. Significant changes in usual functioning (e.g. social, academic).
  • Complexity: Multiple factors impacting young person’s mental wellbeing and functioning. Difficulty managing daily routines, poor academic performance, withdrawal / antisocial behavior. Sudden and unexplained changes in self-care or behavior (appearance, sleep, diet, exercise or withdrawal, isolations, school refusal, highly aggressive, obsessive, antisocial behavior). Or persistent /ongoing distress impacting functioning. Poor hygiene or self-care.
  • Impact: Significant changes in functioning. Interference in most social areas or severe impairment of functioning in one area or multiple areas. e.g. (school refusal 1 week or more or complete refusal, withdrawn, frequent anxiety attacks, aggressive or antisocial behavior.
  • Risk of Harm: Moderate risk of harm to self or others. Thoughts or recurrent thoughts of self-harm or suicide. Aggressive behavior towards others. Regular-excessive drug/alcohol use. Needs considerable supervision
  • Risk Factors: Significant risk factors that often influence functioning and increase risk of mental health issues. Few protective factors.