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Project Overhaul Client Referral Form

Project Overhaul Client Referral Form

Project Overhaul – Queensland Youth Services E: (enquiries only) P: (07) 4410 9376 W: www.qys.org.au

Section 1. REFERRER DETAILS

MM slash DD slash YYYY
Type of Referrer/Relationship to Young Person

Section 2. YOUNG PERSON DETAILS

MM slash DD slash YYYY
Residential Address
Gender

Cultural Identity

Does the young person have regular access to transportation?
If no, can the referring agency provide transportation to/from program activities?

Section 3. PARENT/GUARDIAN DETAILS

Complete this section if the young person is under 18 years of age.
Residential Address
Cultural Identity

Has consent been received from the parent/guardian to progress with this referral?

Section 4. PROGRAM GATEWAY

Select one gateway which the young person wishes to engage in based on interests and location.
Townsville
Mt Isa

Section 5. YOUNG PERSON HISTORY

Identified Risk Factors
Does this young person have a disability or injury?

Support Services

Does this young person have a case plan with another agency? If yes, provide the following.
Is this young person involved with any other services (e.g. ATODS)?

Engagement

Does this young person have a history of actively engaging with services?
Has this young person displayed a willingness to make meaningful change within their lives?
Is this young person willing to actively engage in their selected Project Overhaul gateway, case management and relevant support services if accepted into the program?
Please provide any additional information relating to this referral.
Consent
If the young person being referred is under 18, a parent, guardian or suitable person's (as per section 1) consent is required to proceed.

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