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Please Select a Campus *

Name of person referring *

Referrers contact no *

Referrers email address *

Referrers relationship to young person *

Young Person’s name *

Contact no

Date of Birth

Year

Age

Who does the young person live with *

parent(s)

guardian

carer

other

Please specify

Are there any family orders/ out of home care arrangements *

Yes

No

if yes, please provide contact name

Contact no

Relevant background information

Previous/Current school *

Year Level

Was there additional funding?

Reason for leaving old school (s):

Any other challenges at previous schools

Health

Are there any medical diagnosis:

Developmental/ Learning Needs and Concerns

E.G. Intellectual Disability, Autism Spectrum Disorder

Mental Health Concerns

E.G. Anxiety Disorder – including depression, personality disorder, etc.

Alcohol and/or other drugs usage

Does the young person use substances, how frequently, types of substance

Are there any behavioural issues

E.G; ADHD, ODD, Etc

Is there any Youth Justice Involvement *

Yes

No

Were they in custody *

Yes

No

What kind of order?

Nature of offence: person / property etc.

Is there any DFFH involvement? *

Yes

No

Details:

Name of DFFH Worker

Reason/s for wanting to attend SJFLC

Are there any other services involved

Is there any other helpful information

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Acknowledgement

We acknowledge the Aboriginal and Torres Strait Islander Peoples of Australia as the Traditional Owners and Custodians of the land of our schools. We are inspired and nurtured by their wisdom, spirituality and experience. We commit ourselves to actively work alongside them for reconciliation and justice. We pay our respects to the Elders; past, present and future. As we take our next step we remember the first footsteps taken on this sacred land.

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