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Reconnect Referral Form
Has the young person consented to this referral
(required)
Yes
No
If yes - has consent from the parent/guardian been provided?
Yes
No
Section 1: Referrer Details
First name
(required)
This field is required
Last name
(required)
This field is required
Date of referral
(required)
Please select a date
Email address
(required)
Please enter your email address
Please enter a valid email address
Phone number
(required)
Please enter your phone number
Please enter a valid phone number
Organisation name
(required)
This field is required
Relationship to young person
(required)
Please select a value
-- Please Select --
Case worker/Youth worker
Guidance Officer
Other
If you chose "Other", please specify
Section 2: Young person’s details
First name
(required)
This field is required
Last name
(required)
This field is required
Date of birth
(required)
Please select a date
Email address
(required)
This field is required
Phone number
(required)
This field is required
Residential address
(required)
This field is required
Gender
(required)
Please select a value
-- Please Select --
Male
Female
Non-Binary
Prefer not to say
Cultural Identity
(required)
Please select a value
-- Please Select --
Aboriginal
Torres Strait Islander
South Sea Islander
None of the above
Other
If you chose "Other", please specify
Recent education/employment/training history
(required)
This field is required
Year/duration
(required)
This field is required
Section 3: Parent/Guardian Details
First name
(required)
This field is required
Last name
(required)
This field is required
Relationship to young person
(required)
This field is required
Email address
(required)
This field is required
Phone number
(required)
This field is required
Residential address
(required)
This field is required
Cultural identity
(required)
Aboriginal
Torres Strait Islander
South Sea Islander
None of the above
Other
If you chose "Other", please specify
Section 4: Young Person’s History
Identified Risk Factors (Select all that apply)
(required)
Please tick a checkbox
Homelessness or a risk of homelessness
Disengagement from school, training, employment of community
Mental health issues
Financial issues or lack of income
Legal issues
Disability
Conflict with parents/guardians
Child protection order in place (past or present)
Involvement with other support services
Other
If you chose "Other", please specify
Details about identified risk factors
(required)
This field is required
Young person’s goals to be achieved with Reconnect’s support
(required)
This field is required
Section 5: Consent
I give my consent for this referral to be sent to HBNC’s Reconnect Program with the objective of improving my engagement with my family, education, training, employment or the local community. I also consent to HBNC collecting my personal details for the
(required)
I consent
I do not consent
If the young person being referred is under 16, a parent or guardian’s consent it required to proceed. However, if gaining parent or guardian consent is not possible, an appropriate referrer, as identified in Section 1, can provide consent on their behalf
(required)
Parent/guardian consent provided
Referrer/service provider consent provided
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