Referral Form Test

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Referral Source

Date
Self Referral 
Self-Referral - Referral Source 
Self-Referral - No
Address

Consent is essential for all STTARS Services

We cannot accept a referral without consent.

Has the parent/s consented to this referral if the person is under 18 years? 
Is this person
Can client be contacted directly? 
Please provide other contact details

Person Referred (Client)

Date or Year of Birth
Gender 
Address
Are there any safety concerns for this person?

e.g. contact after 2pm; send SMS before calling; do not leave voicemail?

Having some information about your/this persons background helps us to tailor our services to their needs

Interpreter Required 
Ethnicity

Multiple ethnicities can be included

Does this person self identifies as LGBTIQA+ 
Residency Status 
Client has been in Immigration Detention 
Length of time in immigration detention 
Experienced Statelessness 

Referral Information & Indicators (Will be used to determine eligibility and triage accordingly)

What is the reason for referral? 
Please tick and describe is any of the following are present:

Trauma, Health and Disability Information. Select at least one.

A possible question to ask about torture and trauma is "some people have had bad things happen to themselves and their families. Has anything happened to you or your family that is affecting the way you are feeling now?"

Adults/Adolescents/Children
Additional considerations for Children/Adolescents only
Learning difficulty/cognitive Impairment?
Physical disability and/or chronic illness?

Supports

Please provide details of any other workers/agencies supporting this person and the type of support provided (other than the referring agency). Include NDIS.

Agency details