Referral and Screening Form

Between Multicultural Services and Accoras you.nique

Accoras you.nique is a free and voluntary service, where the child or young person is our client and must be willing to engage with us. Please provide as much information as you have available

Please confirm:

The child or young person is aware of this referral and is willing, motivated and able to engage with Accoras you.nique to overcome challenges and work towards individual goals, and the parent/carer of the child or young person has consented to this referral being made.

Referral Details
Date of Referral
Referrer name and position
Contact number and email address
Child or young person details
Full name & preferred name
Date of birth/Age of young person
Gender / ☐Male ☐Female ☐Intersex
Mobile number (if appropriate)
Home address
Country of Birth
Ethnicity
When did the child or young person (or their family) arrive in Australia?
Does the child or young person speak any languages other than English? / ☐No
☐Yes - language:
Does the child or young person require an interpreter? / ☐ No
☐ Yes - language:
Which cultural & religious groups does the child or young person identify with?
Is the child or young person engaged in schooling? / ☐No
☐Yes – which school:
Parent or carer details
Full name/s & preferred name/s
Relationship/s to child or young person
Contact details
Home address/es:
Do the parents or carers require an interpreter? / ☐No
☐Yes - language:
Family Composition
Reason for referral
Summary of services provided to young person
Are the family linked with other support services? If yes, what support is provided?
Does the child or young person have a confirmed or suspected diagnosis in any of these areas?
☐Mental health concern
☐Physical health concern
☐Developmental/Learning disorder
☐Other
Details:
Please provide more information to help us determine the needs of the client or young person:
The child or young person is:
☐Feeling stressed, anxious or nervous
☐Feeling down, sad or depressed
☐Lacking self-esteem or confidence
☐Feeling angry or frustrated
☐Experiencing settlement difficulties
☐Experiencing social/family difficulties
☐Difficulties with relationships
☐Experiencing trauma related symptoms:
☐Loss of already achieved skills e.g. bed wetting
☐Re-enactment of events e.g. nightmares
☐Avoiding feelings related to trauma
☐Other (please describe below)
Details:
What outcomes would you like to see as a result of us working with the child or young person?

Please send the completed form to

To speak to us about a referral, please call our team on

3255 6555 (South Brisbane) or 5679 3300 (Gold Coast)

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