REFERRAL TO YOUTH CONNECTIONS
Section 1 - Participant being referred Participant Details Contact Details
Please indicate preferred contact method (tick one) Surname: Address: ( Given names: Date of birth: ......../....../...... Age: Gender: Male Female Suburb: Highest year level attended at school: State: Postcode: Currently at school Disengaged for less than 3 months
Disengaged for more than 3 months Phone: ( School name: Mobile: ( Training programs attended: Email: ( Is the participant receiving payments from Centrelink, eg Youth Allowance?
( Yes ( No ( Unaware Is the participant registered with a Job Services Australia Provider?
( Yes ( No ( Unaware
Section 2 - Referrer's details
Organisation Details Contact Details Organisation Name: Address: Contact Person: Suburb: Email: State: Postcode: Position: Phone: Date of Referral:
When referring a young person to receive assistance through Youth Connections the young person must meet the eligibility criteria. The main focus of Youth Connections in Queensland is to assist young people who are 14 to 18 years of age and are:
* 'Severely disengaged' from school, education, training or work, family and/or community. It is expected that this young person would not have attended school for at least three months.
* 'At imminent risk' of disengaging from school or another education environment or has disengaged within the last three months
If the young person does not fit within these criteria, please contact Youth Connections on (07)55386600 as alternative service providers may be available to assist.
Please tick all barriers relating to the young person being referred. Please be aware that at least ONE barrier must be ticked.
IDENTIFIED BARRIERS
Educational
Poor literacy / numeracy skills
Low school achievement
Behavioural issues
High incident of truancy
History of suspension
History of expulsion
Personal
Self esteem issues
Poor social skills
Mental health issues
Substance misuse issues
Disability
Medical condition
Carer responsibilities
Social, cultural, community
Bullying
Family difficulties
Homelessness or at risk of
Out of home care
Long term unemployed (> 6 months)
Significant financial issues
HISTORY OF SUPPORT
To the best of your knowledge, is the young
person receiving, or has recently received,
support from any of the following services:
In school support (i.e. learning, counseling)
Aboriginal Community Liaison Officer
Distance Education
Other / Alternative Education
Job Services Australia
Reconnect
Youth Worker
Headspace or other counseling service
Sexual Health
Supported Accommodation
Juvenile Justice
Other: _____________________________
Reasons for referral (an outline of the issues involved and how you believe these issues affect the young person's ability to participate effectively in education or training). If there is insufficient spaces please attach an additional page. Please be aware that no referral will be accepted if sufficient information is not provided.
Where possible please provide documentary evidence e.g. Absence reports, academic reports, etc.
Risk factors might include but are not limited to: Educational, Personal, Social, Health.
Please send referral to the Youth Connections Manager Katrina on katrina@scisco.org.au or fax on (07) 5538 6645. Enquiries contact SCISCO on (07) 5538 6600 Page 1 of 2
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