Evolution Art Program Referral Form (September 2015)
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- Nathaniel Welch
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1 (September 2015) Section A This section is to be completed by the young person or with the support of the referring worker. Please fax completed referral form to Frontyard Youth Services, Attention: Mitchell Gainey on (fax) or to frontyard@mcm.org.au If you have any questions please call Date: / / Client details Full Name(s): Date of Birth: / / Age: Gender: Male Female Address: Postcode: Contact number: Mobile: Cultural Identity: Do you have any children? Do you have any Allergies? Do you have any dietary requirements? Frontyard Youth Services 19 King St, Melbourne Phone: Freecall: frontyard@mcm.org.au 1.
2 Education, Employment and Training (E.E.T) What is the highest level of education you completed at School? Year 7 or Below Year 8 Year 9 Year 10 Year 11 Year 12 Other Have you completed or partially completed any Tafe, Tertiary or Short Courses? (if yes, please provide details) Why have you chosen to do the EVOLUTION Program? What type of artform do you most enjoy? Is there any of the following that may affect your attendance to the program? Housing Appointments Legal matters Drug/Alcohol issues Transportation Mental Health Health Issues Are you currently receiving any financial support/government benefits? Youth allowance Abstudy Austudy Newstart DSP Single Parent Pension Parenting Payment Frontyard Youth Services 19 King St, Melbourne Phone: Freecall: frontyard@mcm.org.au 2.
3 Section B To be completed by the referring worker. Workers Details Name: Contact Details: Office: Mobile: Address: Education, Employment and Training (E.E.T) Is the young person currently linked in with any other key worker or organisation that may currently be supporting them with Education, Employment or Training? If yes, Name of Organisation/Program: Name of Worker: Contact No: Housing/ Accommodation Status What is the young person s accommodation situation? Youth Refuge Adult Refuge Transitional Housing Office of Housing Lead Tenant Private Rental Shared Housing Rooming House Student Accom Friends/Family Couch Surfing Is the young person currently receiving support from a housing worker? Frontyard Youth Services 19 King St, Melbourne Phone: Freecall: frontyard@mcm.org.au 3.
4 Drug & Alcohol Use Does the young person have any current substance use issues? If Yes, which of the following are being used? Alcohol Amphetamines Cannabis Cocaine Ecstasy Heroin Is the young person currently receiving support from a D&A worker? Mental Health Has the young person been diagnosed with a mental health issue? If Yes what is the diagnosis? Anxiety Bipolar Disorder Borderline Personality Disorder Depression Schizophrenia Panic Disorder Post Traumatic Stress Psychosis Other Is the young person currently linked in with any mental health supports? Is the young person currently taking any medication for their diagnosis? If yes, Medication: Frontyard Youth Services 19 King St, Melbourne Phone: Freecall: frontyard@mcm.org.au 4.
5 General Health Are there any general health concerns that we need to be aware of? Legal Issues Does the young person have any current legal issues that may prevent them from attending Evolution on a regular basis? If yes, what outstanding matters does the young person have? Fines Involvement with Police Criminal Court Youth Justice Order Community Based Order Other Supports: Is the young person currently linked in with any other support services? If yes, Name of Organisation/Program: Name of Worker: Contact No: Frontyard Youth Services 19 King St, Melbourne Phone: Freecall: frontyard@mcm.org.au 5.
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