Chameleon upcycled products

Chameleon Upcycled Products Client Referral Form

Chameleon Upcycled Products Client Referral Form

Chameleon Upcycled Products program - Queensland Youth Services E: (enquiries only) P: (07) 4410 9376 W: www.qys.org.au

Section 1. REFERRER DETAILS

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

Section 2. YOUNG PERSON DETAILS

DD slash MM 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. YOUNG PERSON HISTORY

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

Section 5. 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)?

Section 6. 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?
Will this young person actively engage in case management and support services if accepted?
Please provide any additional information relating to this referral.
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.