Youth Clinical Care & Coordination Referral Form

Youth Clinical Care & Coordination
(YCCC) Referral Form

Please complete all information required in the form fields below

Date of Referral

Clinician Name

Program Referring to:
YCCC Clare
YCCC Whyalla
YCCC Port Augusta

Client Details

Full name

Preferred name

Gender

Preferred Pronouns

Date of Birth

Address
Address Line 1
City
State / Province / Region
Postal Code
This service is only available within South Australia. Check our services page for specific locations. Or contact Head to Health directly on 1800 595 212 or visit website www.headtohealth.gov.au for alternative services in their area.

Above address is my postal address
Yes
No

Is it okay for us to send headspace branded documents to this address?
Yes
No

Phone

Is it okay for us to contact you via SMS?
Yes
No

Email Address

Is it okay for us to send information via email?
Yes
No

Details

Client’s Key Contact Person (in case of emergency)

Name

Phone

Relationship to young person

Cultural Background

Are you of Aboriginal or Torres Strait Islander origin?
Aboriginal
Torres Strait Islander
Both
Prefer not to say

Cultural Background

Language spoken

Interpreter Required
Yes
No

Spirituality / Beliefs

Are there any spiritual or cultural factors that you want us to be aware of? If so please list them below

Referrer Details

Is this a self referral?

Name of Referrer (if NOT self-referral)

Referrer Phone

Referrer Fax

Referrer Email

Relationship to Young Person

GP Details

Does the young person have an existing GP?
(Please note this is not required to access YCCC services)

Does the young person have a Mental Health Treatment Plan?

Young Person Supports & Consent

Does the young person consent to referral?

If under sixteen, do caregivers consent to referral?

Does the young person consent to sharing information with other agencies to ensure appropriate care?

Caregiver 1 Name

Caregiver 1 Signature

Clear Signature

Caregiver 2 Name

Caregiver 2 Signature

Clear Signature

Young Person Signature

Clear Signature

IMPORTANT INFORMATION ABOUT YOUR REFERRAL- PLEASE READ

CObH provides free and confidential services for young people aged between 12-25 years, who consent to receiving support. CObH is not a crisis service, if the young person is in crisis or are at acute risk of harming themselves or others, please contact emergency services on 000. In a mental health emergency please contact Mental Health Triage on 13 14 65 (16+ years) or Kids Helpline 1800 55 1800. Once a referral form has been received the CObH team will make contact. Waitlist - given the demand for CObH services, there may be a waitlist at times. You will be advised by a CObH staff member via phone call or letter. Please seek support from your GP or local hospital should your situation change. We recommend a list of services including Beyond Blue 1300 224 636 and Lifeline 13 11 14.

Reason for Referral

(What are the current issues and what support do you need? Please include info about the duration, age of onset and pre-existing diagnoses. Please attach further information/relevant assessments, reports etc.)

Mental Health Support
Yes

Alcohol and Other Drug Support
Yes

Other Concerns
Yes

Please upload further information/relevant assessments, reports etc.

Click or drag files to this area to upload. You can upload up to 5 files.

Risk Factors (self / referrer to complete)

Please check the appropriate boxes below

Suicidal thoughts

Yes No

Present in last 4 weeks
YesPresent in last 4 weeks Yes
NoPresent in last 4 weeks No
Past issue
YesPast issue Yes
NoPast issue No

	Yes	No
Present in last 4 weeks	YesPresent in last 4 weeks Yes	NoPresent in last 4 weeks No
Past issue	YesPast issue Yes	NoPast issue No

Suicidal behaviour (plans/intention to act)

Yes No

Present in last 4 weeks
YesPresent in last 4 weeks Yes
NoPresent in last 4 weeks No
Past issue
YesPast issue Yes
NoPast issue No

	Yes	No
Present in last 4 weeks	YesPresent in last 4 weeks Yes	NoPresent in last 4 weeks No
Past issue	YesPast issue Yes	NoPast issue No

Deliberate Self harm

Yes No

Present in last 4 weeks
YesPresent in last 4 weeks Yes
NoPresent in last 4 weeks No
Past issue
YesPast issue Yes
NoPast issue No

	Yes	No
Present in last 4 weeks	YesPresent in last 4 weeks Yes	NoPresent in last 4 weeks No
Past issue	YesPast issue Yes	NoPast issue No

Thoughts of harming other people

Yes No

Present in last 4 weeks
YesPresent in last 4 weeks Yes
NoPresent in last 4 weeks No
Past issue
YesPast issue Yes
NoPast issue No

	Yes	No
Present in last 4 weeks	YesPresent in last 4 weeks Yes	NoPresent in last 4 weeks No
Past issue	YesPast issue Yes	NoPast issue No

Hospital presentation (for mental health)

Yes No

Present in last 4 weeks
YesPresent in last 4 weeks Yes
NoPresent in last 4 weeks No
Past issue
YesPast issue Yes
NoPast issue No

If selected “yes” to suicidal behaviour or hospital presentation in last four weeks, please contact headspace Port Augusta on 8641 4300 to discuss referral.

	Yes	No
Present in last 4 weeks	YesPresent in last 4 weeks Yes	NoPresent in last 4 weeks No
Past issue	YesPast issue Yes	NoPast issue No

If you selected “yes” to suicidal thoughts and/or deliberate self-harm. Do you have a safety plan?
Yes
No

Risk Details

Medications
(Please list below any current or previous medications that a client or young person has been on for the treatment/management of a mental health illness)

Any Other Relevant Information
(Please list below any current or previous medications that a client or young person has been on for the treatment/management of a mental health illness)

Email

Youth Clinical Care & Coordination (YCCC) Referral Form