• Intake & Referral Form

    Welcome! Let's get a better understanding of your young person’s needs. The information you provide will assist us in creating the most appropriate support experience. Your progress will automatically save, allowing you to complete it over multiple sessions if required. All information provided will remain strictly confidential and will only be used for the purpose of delivering our services.
  • Who is completing this form?*
  • Are you completing this form with the young person's input?*

  • Support Coordinator/Plan Manager/Guardian Details

  • Would you like to be included in updates about the participant?*

  • Participants Details

  • Date of Birth:*
     / /
    2 digit day, 2 digit month, 4 digit year

  • Emergency Contact

  • What is the relationship to the young person?*

  • Funding

  • How will mentoring services be funded?*

  • NDIS Details

  • Which NDIS Plan Category would you like to use for youth support.*
  • I give Reaching Youths have permission to contact the Support Coordinator/Plan Manager*

  • Medical Information

  • Does the client have any allergies?*
  • Does the client have any medical conditions or disabilities we should be aware of?*
  • Is the client currently on any medications?*

  • Support Needs

  • Previous therapy/support experiences*

  • Support Goals

  • Which of the following goals would you like to achieve?*

  • Communication Preferences

  • Preferred method of contact:*
  • Best time to contact:*

  • Support Preferences

  • Preferred days:*
  • Preferred time:*
  • Ideal hours per session:*
  • On-Going Sessions*
  • Youth worker gender preference?*
  • What qualities are most important to you?*

  • Permissions & Consent

  • Please read through the following and provide consent where appropriate. This section ensures we have your permission to support your child safely and respectfully.

  • I consent for my child/myself to participate in support sessions with Reaching Youths*
  • I understand sessions may take place in community locations (e.g. parks, cafés, activity centres).*
  • I consent for my child to be transported by their assigned youth support. (Travel will be provided in accordance with Reaching Youths' policies and procedures).*
  • I consent to photos or videos being taken for Reaching Youths use (e.g. reports, website, social media, advertising materials).*
  • I understand my information will be kept private and confidential, except where required by law.*
  • How did you hear about Reaching Youths*
  • Date*
     / /
    2 digit day, 2 digit month, 4 digit year

  • Thank you for taking the time to provide this detailed information.

    Next Steps:
    Our team will review your responses and contact you within two business days to discuss support matching and arrange a meet and greet session.

    If you need to update any information or have any urgent enquiries, please contact us on 0434 310 110 or enquiries@reachingyouths.com.au

    Thank you for placing your trust in us to support your young person.

  • Should be Empty: