Service Information and Referral Criteria

SERVICE INFORMATION AND REFERRAL CRITERIA

Youth health is afree, voluntary serviceprovided to young people who frequent / live/work/studyin theWESTERN SYDNEY Local Health District (Parramatta, Auburn, Holroyd, Baulkham Hills, Blacktown and Mt Druitt). Youth Health has a focus on preventing harm and injury, oral health, physical health and nutrition, mental health, sexual health and alcohol / other drug use, including tobacco for marginalised, disadvantaged or at risk young people.

There are two youth health service sites in Western Sydney:

• High Street Youth Service

65High Street, Harris Park – Ph: 8860 2500 Fax: 9687 2731

• Western Area Adolescent Team
  Corner of Kelly Close & Buran Close, Mount Druitt – Ph: 9881 1230 Fax: 9625 9110
• There are a number of additional youth health sites across NSW – for further information

The Engaging Adolescents Program is being provided by Youth Health for parents of our target group to enhance their ability to support their adolescent children. This is a voluntary program for those who agree to participate.

A participation agreement will need to be signed outlining levels of confidentiality, expectations and personal responsibilities.

REFERRER (INDIVIDUAL COMPLETING THIS FORM)

Contact Name:Position / Relationship:

Organisation (if applicable):

Address:Suburb:Post Code:

Postal Address (if different from above):

Phone: Mobile:Fax:

Email:

Signed: Date:______

PARENTS DETAILS: *Required Information

Do you consent to this referral? Yes ☐ No ☐

PARENT 1

Given Names: Surname:

Date of Birth:Current age:

Gender: M☐ F☐Other☐ (please specify) Preferred Name:

Relationship to Child/Children:

Address: Suburb: Postcode:

Home Phone:

Mobile:

Signed: Date: ______

Do you consent to this referral? Yes ☐ No ☐

PARENT 2

Given Names: Surname:

Date of Birth:Current age:

Gender: M ☐ F☐Other☐ (please specify) Preferred Name:

Relationship to Child/Children:

Address: Suburb: Postcode:

Home Phone:

Mobile:

Signed: Date: ______

CHILD / CHILDRENS DETAILS: *Required Information

Child 1: Name:

D.O.B. Age Gender M ☐ F☐Other☐ (please specify)

Child 2: Name:

D.O.B. Age Gender M ☐ F☐Other☐ (please specify)

Child 3: Name:

D.O.B. Age Gender M ☐ F☐Other☐ (please specify)

Child 4: Name:

D.O.B. Age Gender M ☐ F☐Other☐ (please specify)

Are the child / children in your care part time or permanently?

Where are the child / children residing if not with you?

Are there any concerns or important information that we need to be aware of?

LegalYes ☐ No ☐

SafetyYes ☐ No ☐

Violence and / or AggressionYes ☐ No ☐

AbuseYes ☐ No ☐

Child Protection concernsYes☐ No ☐

Domestic and Family ViolenceYes ☐ No ☐

Mental HealthYes ☐ No ☐

Substance useYes☐ No ☐

Other, please specify:

Are there any other support services involved with your family? Yes ☐ No ☐
If YES – Please provide the name of the organisation/s and their support role

How did you hear about this parenting program?

What are your main concerns about parenting your child/children?

What skills are you hoping to develop through attending the Engaging Adolescents Program?

What areas of support would you like assistance with?

WHAT NEXT?

For High Street Youth Health Service, Harris Park please send completed form to: FAX: (02) 9687 2731

For Western Area Adolescent Team, Mount Druitt please send completed form to: FAX: (02) 96259110

Engaging Adolescents Program Referral Form V1 March 2016

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Thank you for your interest in the Engaging Adolescents Program.

Once received, a facilitator will contact you to discuss your request.

Engaging Adolescents Program Referral Form V1 March 2016

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