Sir David Martin Foundation - Helping young people in crisis

Triple Care Farm Referral Form

Contact Details
Date
First Name*
Surname*
Gender*	MaleFemale
Phone Number*
Mobile
Current Address
No fixed address
Date of Birth
Age
First Admission	YesNo No
If no, how many times has the client been to Triple Care
Problematic drug or alcohol use*	YesNo
If No, please specify nature of issue. We will endeavour to find an appropriate referral

Details of Referrer
Referrers Name*
Agency/Relationship to client*
Address
Postcode
Phone
Type of Referral	DocsJuvenile Justice Mission AustraliaHealth Mental HealthPrivate Other (Self, Relative, Friend)

Care Status
Care Status	Juvenile Justice supervisonParent Courts ordered careSelf (over 18 years old) DoCS
Name of District Officer
Address
Postcode
Phone
Name of Juvenile Justice Officer
Address
Postcode
Phone
Name of Mother
Mother's Address
Postcode
Phone
Name of Father
Address
Postcode
Phone
Legal Guardian (if client under 18 years of age)
Address
Postcode
Phone

Identification Information
Medicare Number
Tax File Number
Birth Certificate	YesNo

Medical Information
Significant medical conditions
Ongoing prescribed medication

Emergency or Exit Contact
1. Legal Guardian. Name
Address
Postcode
Phone
2. If Unavailable Contact. Name
Address
Postcode
Phone

Personal Details
Country of birth*
Preferred language
Aboriginal Torres Strait Islander	YesNo
Non-english speaking background	YesNo
Requires an interpreter	YesNo
Language
Have any disabilities?	YesNo
Please specify

Income Status
Income Status (Tick all that apply)	Unemployment benefitStudy benefit Disability benefitHomeless benefit Parental SupportFull time employment Part time employmentCasual employment No incomeOther
Please specify

Education Details
Grade on leaving school
Reason for leaving
Comments

Training Status
Training Status (Select one)	Accredited vocational trainingNon-accredited training Employment trainingEmployment training Not In TrainingOther
Employment Training: Please Specify
If Other, please specify

Background
Sexually Abused	YesNo Don't know
Physically abused	YesNo Don't know
Attempted suicide	YesNo Don't know
If yes, please comment
Are there any problems with Drug Abuse	YesNo Don't know
Are there any problems with Alcohol abuse	YesNo Don't know
Are there any problems with gambling?	YesNo Don't know
If yes, please comment
Are there any police charges	YesNo JJ Supervision
List charge details
Comments (outstanding matters, court dates fines etc)

Family
Family details including history and siblings

Referee details
Agency Name (Another agency client is known to)*
Contact Name
Contact phone number

Confirmation
I confirm to the best of my knowledge that the information above is correct*	YesNo
Date*
Please confirm full name*

* Denotes a required field