YOUTH – Empower Youth – Referral Form Empower Youth – Referral Form * indicates required field 1Referrer2Young Person 3Acknowledgement The personal, sensitive and health information collected will be used by Swan Hill Rural City Council Empower Youth Program for the primary purpose of: Ensuring the young person is provided with meaningful and appropriate support during specific program and general service delivery Ensure parents/guardians/ workers can easily be contacted if required Information about the young persons’ participation in the program and topics arising will also be shared with the nominated person/s or organisation/s listed in this referral, with the young persons’ consent. The information the young person provides shall remain private unless disclosure is required by law, or consented by the young person and will be handled in accordance with the Privacy and Data Protection Act 2014 (Vic).Person referringType of referral* Self referral Parent / Guardian referral Agency Referral Relationship to young person* Full name* Mobile* Home/Business* Organisation* Young person's detailsFull name* Preferred name Mobile Email Address* Date of birth* DD slash MM slash YYYY Age* Gender The young person is under 16 years. Are the parents / legal guardians aware of this referral?* Yes No Education / EmploymentDoes the young person attend secondary school?* Yes No What school do they attend?* Highest level of education*--Year 6Year 7Year 8Year 9Year 10Year 11Year 12 / equivalentCertificate IICertificate IIICertificate IVDiplomaBachelor Degree or higherEmployment status*--Unemployed, not looking for workUnemployed, looking for part time/casual workUnemployed, looking for full time workEmployed, Part timeEmployed, CasualEmployed, Full timeVoluntary workSupportFor what areas is support require?*Tick all that apply Family & relationships Housing & accommodation Education & training Vocational skills, career pathways & employment Physical health Mental health Emotional health Alchol and/or other drugs Financial Other Other CultureLanguage/s spoken* Cultural background* Aboriginal or Torres Strait Islander descent?* Yes No Australian Citizen?* Yes No What visa does the young person have?* A perminent visa Another type of visa Please specify Visa type* Living arrangementsWho currently lives at home?*Tick all that apply Just me Mum Dad Siblings Other relatives Friends / roommates Other Other: Are there any court orders/custody arrangements?* Yes No Please upload a copy of the court order/custody arrangement*(Max file size: 3MB. Accepted file types: pdf, jpg, png, doc, docx) Drop files here or Select files Accepted file types: pdf, jpg, png, doc, docx, Max. file size: 3 MB, Max. files: 2. Health and wellbeingPlease indicate if any of the following applyTick all that apply Allergies Asthma Epilepsy Learning disability Physical disability Mental Health (ie. depression / anxiety) Other Please specify any treatment/ medication*Support ServicesDoes the young person currently receive support from any other services?* Yes No Please list and provide detailsAgency nameContact name and phoneServices being provided / areas being supported AcknowledgementAcknowledgement* I acknowledge that the information collected on this form is true and correct Full name*
