RACR Youth Programs – Service Referral Form

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RACR Youth Programs – Service Referral Form

Client is aware of and has verbally consented to this referral *

Client is aware they will be contacted by a RACR Practitioner for a safety and needs assessment *

Client understands that the program is voluntary *

Is the Client under the age of 16 years? *

Please provide information your service is aware of at the time of the referral. We are seeking to support trauma informed practice by not requiring the client to disclose their story regularly. If you do not have the information requested, please mark the section as unknown and send us what information you do hold.

Program Referral *

Case Management
Group Engagement

Organisation Details

Organisation Name *

Worker Name *

Contact Phone *

Contact Email *

Confirm Email

Client Details

Full Name *

Date of Birth *

Gender *

Pronouns *

Phone Number *

Contact Address *

Address Line 1

City

State / Province / Region

Postal Code

Email *

Confirm Email

Additional details we may need:

Interpreter required?

Yes
No
Unknown

Other considerations (E.g cultural, linguistic, gender identity, disability etc)

Any current experiences of Family, Domestic or Intimate Partner Violence *

Yes
No
Unknown

Current Protection Orders or Police Involvement *

Yes
No
Unknown

Perpetrator Details (If Known)

Please include name, DOB, relationship to client and level of current involvement with client.

History of Violence Experienced by Client or Clients Family (If Known)

Please include any information on incidents, duration, patterns, and forms of abuse, etc.

Current Concerns (If Known)

Please include information pertaining to current risk or escalation of violence. Including any information on concerns for the client around AOD use, Homelessness or Mental Health that we should be aware of.

Client Supports (If Known)

Please include any information about supports for the client. Including agencies involved, informal supports such as friends as well as use of protective behaviours or a current safety plan in place.

Any additional referral information

Please include any further information around safety, situation and needs that may support this referral and client engagement.

Phone 1300 364 277

We are not a crisis service
If you are in crisis call Lifeline 13 11 14
If you are in immediate danger call 000

Relationships Australia Canberra & Region Incorporated is accredited by Quality Innovation Performance (QIP) against the QIC Health and Community Services Standards 7th Ed.

If you find it difficult to hear or to speak, you can contact us through the National Relay Service (NRS). Please call 133-677

If you require support in another language, you can use the Translating Interpreting Service (TIS) free of charge by calling us and asking for an interpreter or calling TIS on 131 450 and asking to be connected to us on 1800 364 277

Child Safety and Wellbeing | Privacy and Confidentiality

Relationships Australia Canberra & Region Incorporated is accredited by Quality Innovation Performance (QIP) against the QIC Health and Community Services Standards 7th Ed.

In the spirit of reconciliation, Relationships Australia Canberra & Region acknowledges the Traditional Custodians of country throughout Australia and their continuing connection to land, sea and community. We pay our respects to their Elders past, present and future. We extend our respect to all Aboriginal and Torres Strait Islander Peoples visiting this website.

RACR Youth Programs – Service Referral Form