Family Mental Health Support Services (FMHSS) Referral

Date of referral *

Details of person making referral

Referrer's Firstname *

Refererr's Surname *

Referrer's email *

Referrer's phone number (DIRECT) *

Referrer's Agency & Program/Service *

Referrer's role *

Is there current involvement with the Department of Child Protection? *

YesNo

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

Is the child or young person aware that this referral is being made? *

YesNo

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Child or young person details

Child/young person's Firstname *

Child/young person's Surname *

Child/young person's date of birth *

Age

Child/young person's gender *

MaleFemaleOther

Child/young person's home address *

Post code *

Country of birth *

Main language spoken at home? *

Is an interpreter required?

YesNo

Education *Early years or school enrolled

Child/young person's cultural identity *

AboriginalTorres Strait IslanderBothNeither

Does the child/YP have: *

Mental Health diagnosis No/Yes prompt to details Neurodiversity diagnosis Diagnosed physical health issues? None

Please provide details: *

What is currently working well for the child/Young Person? *

Support Network

Please select support services the child/YP is currently engaged with: *

Family members School support Community or cultural support (including clubs, youth groups, sporting etc.) Wellbeing/mental health services Disability support Health support Other

Provide details: *

Is the child/YP regularly attending school? *

YesNo

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Parent/Guardian contact details

Firstname *

Surname *

Relationship to Child/Young Person *

Address *

Post code *

Mobile number *

Email Address *

Council area *

Country of Birth: *

Main language spoken at home *

Is an interpreter required? *

YesNo

Parent/Guardian's cultural identity? *

AboriginalTorres Strait IslanderBothNeither

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People living in the household

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

Are there any Parenting Plans or Parenting Orders in place? *

YesNo

Please Provide details:

Are there any Intervention Orders in place

YesNo

Please Provide details:

Reason for referral

What are the signs the child/YP may be at risk of developing wellbeing concerns? *

Changes in behaviour Disturbed sleep Changed eating habits Social difficulties Persistent worry Lack of interest in normal activities or interests

Please Provide details: *

Are there significant life events or changes within the family, previous or current? *

Family separation Death of significant person, including pets Family violence Moving home Changing schools Relationship challenges Physical health issues

Please Provide details: *

What is the parent or child’s expressed hope for engaging with our service? *

Risk factors

Self-harm *

Yes No

Suicidal ideation *

YesNo

Mental health issues (child or family) *

YesNo

Alcohol or other drugs usage (child or family) *

YesNo

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

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UnitingCare Wesley Bowden Inc ABN 65 440 352 199

77 Gibson Street, Bowden SA 5007

Rev.11/21 V1