Family Mental Health Support Services (FMHSS) Referral

Date of referral *

Details of person making referral

Referrer's name *

Referrer's email *

Referrer's phone number *

Agency (where applicable)

Referrer's role *

I confirm that the parent/care giver has given consent and is willing to work with the program *

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Child or young person details

Child/young person's name *

Child/young person's date of birth *

Age

Country of birth *

School or educational facility *

Child/young person's home address *

Post code *

Child/young person's phone number

Child/young person's email address

Child/young person's gender *

MaleFemaleIntersexIndeterminate

Child/young person's cultural identity *

AboriginalTorres Strait IslanderBothNeither

CALD *

YesNo

If yes, is an interpreter required?

YesNo

If yes, which language?

Main language spoken at home?

Is there an existing mental health/physical diagnosis? *

YesNo

Parent/Guardian contact details

Name *

Address *

Post code

Council area *

Phone - Mobile

Email Address *

Parent/Guardian's cultural identity? *

AboriginalTorres Strait IslanderBothNeither

Parent/Guardian's date of birth *

CALD *

YesNo

If yes, is an interpreter required? *

YesNo

If yes, which language?

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Household composition

e.g. family members, relatives, friends, etc. living in same household as the child/young person

Name

Date of birth

Relationship to child/young person

Name

Date of birth

Relationship to child/young person

Name

Date of birth

Relationship to child/young person

Name

Date of birth

Relationship to child/young person

Name

Date of birth

Relationship to child/young person

Name

Date of birth

Relationship to child/young person

Orders & Interventions

Is the parent/guardian willing to participate? *

YesNo

Are there any custody orders in place? *

YesNo

Are there any parenting plans in place? *

YesNo

Are there any court orders in place? *

YesNo

Is there involvement with the Department of Child Protection? *

YesNo

Is there involvement with the the police? *

YesNo

If you responded YES to any of the above, please provide details

Referral details

Are there early signs of wellbeing difficulties e.g. changes in mood /energy /motivation /concentration levels, excessive or persistent worry, issues with memory, withdrawn, changes in behaviour / behavioural concerns, changes in interests or social engagement *

Yes (please provide details below)No

Details

Are there any difficulties with friendships/social relationships? *

Yes (please provide details below)No

Details

Are there any challenges in family relationships? *

Yes (please provide details below)No

Details

Are there any eating or sleeping problems (e.g. significant weight gain or weight loss, nightmares, too much or not enough sleep, difficulty falling or staying asleep)? *

Yes (please provide details below)No

Details

Are there any life transitions/significant change e.g. moving house, changing schools? *

Yes (please provide details below)No

Details

Are there any loss and grief (family breakup, death of a family member)? *

Yes (please provide details below)No

Details

Are there any significant life events; family violence, family separation, loss and grief? *

Yes (please provide details below)No

Details

Are there family mental health *

Yes (please provide details below)No

Details

Are there any social isolation issues? *

Yes (please provide details below)No

Details

Is there any drug or alcohol use? *

Yes (please provide details below)No

Details

Are there any health issues? *

Yes (please provide details below)No

Details

Is there any school absence/refusal? *

Yes (please provide details below)No

Details

Risk factors

Suicidal ideation/self-harm *

Yes No

Domestic & family violence *

YesNo

Homelessness *

YesNo

Worker safety *

YesNo

If you responded YES to any of the above, please provide details

Support network

Please detail any services the child/young person is engaged with.

Mental health service *

Yes No

Other agencies *

Yes No

Family members *

Yes No

Cultural supports *

Yes No

Health services *

Yes No

Other *

Yes No

If you responded YES to any of the above, please provide details(include name and phone number where possible)

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UnitingCare Wesley Bowden Inc ABN 65 440 352 199

77 Gibson Street, Bowden SA 5007

Rev.11/21 V1