Individual Support Form

Has the young person consented to this referral?: *

Support required: * Casework Support (Central Coast) Casework Support (Newcastle) Drug & Alcohol Counselling (Central Coast) Drug & Alcohol Psychology (Newcastle) - REFERRALS ARE CURRENTLY CLOSED

First & Last Name: *

Preferred Name:

Preferred Pronouns:

DOB: *

Age: *

Gender: * -- Please Select -- Female Male Prefer not to say Other

Cultural Identity: * Aboriginal Torres Strait Islanders Australian Other

Current Address: *

Living Arrangement:-- Please Select -- Alone Spouse/Partner Alone with child(ren) Spouse/partner and children Parent(s) Other relative Friend(s) Friends, parents, relatives and child(ren) Not known / not stated / inadequately described Other

Usual Accomodation:-- Please Select -- Boarding House Health - Community Mental Health, residential Hostel/supported accommodation services House/Flat, Rented Privately owned house or flat Shelter / Refuge No usual residence / homeless Not Stated / Inadequately described Unknown / Don't Know Other

Principal Source of Income:-- Please Select -- Full-time employment Part Time Employment Temporary Benefit (e.g. unemployment) Pension (e.g. aged, disability) Student Allowance Dependent on others No income Not Stated / inadequately described Other

Contact phone number for young person: *

Emergency Contact Name & Number: *

Details of Referral: *

Are there any significant risk & safety concerns we should know about?: *

AOD (Alcohol and Other Drugs):

Ever had treatment for AOD use or gambling problems?: Yes No

Mental Health:

Disabilities:

Other Support:

Name and location of referring agency/service: *

Referrer contact phone: *

Referrer Email: *

Confirm Referrer Email: *