Reconnect Client Referral form

Reconnect is a national program funded by the Department of Social Services, delivered by Queensland Youth Services (QYS), visit https://www.dss.gov.au/families-and-children-programs-services/reconnect. To receive support services from QYS’ Reconnect program, a young person must: be 12 to 18 years old, and live, work or attend school in Townsville, QLD

Section 1 - REFERRER DETAILS

Date of Referral(Required)

Primary Contact Number(Required)

Organisation(Required)

Section 2 - YOUNG PERSON DETAILS

Date of Birth(Required)

Primary Contact Number(Required)

Section 3 - PARENT/GUARDIAN DETAILS

Relationship to Young Person(Required)

Primary Contact Number(Required)

Parent/Guardian Signature

Section 4 - YOUNG PERSON HISTORY

If any risk factors have been selected above, further details MUST be provided below.(Required)

Identify the young person’s goals to be achieved via Reconnect’s support.(Required)

NOTE: YP must have a goal for at least one primary risk factor.