Reconnect - QYS Program

Reconnect Client Referral Form

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

MM slash DD slash YYYY
Relationship to Young Person

Section 2 - YOUNG PERSON DETAILS

MM slash DD slash YYYY
Residential Address
Gender
Cultural Identity

Section 3 - PARENT/GUARDIAN DETAILS

Address
Has consent been received from the parent/guardian to progress with this referral?
If yes, please sign below

Section 4 - YOUNG PERSON HISTORY

Identified Risk Factors