CONFIDENTIAL
YOUTH PROGRAMME: REFERRAL FORM
Date of Referral:
Client Information
(Online referrals- highlight boxes; Paper referrals- tick boxes)
Name:
Date of Birth:
Other Names:
Age:
Ethnicity:
Gender
M
F
Other
Iwi:
Current Address:
Referral Source
Name:
Agency:
Address:
Phone:
Fax:
Email:
Referral Question: What questions do you want answered by this referral?
Assessment of young person’s / family’s risks and strengths regarding harmful sexual behaviour
Will young person benefit from specialist intervention at WellStop and are they motivated to do so?
What are the factors that have led young person to engage in sexually harmful behaviour?
Can young person be treated safely in the community?
How can family/school manage young person’s sexually harmful behaviours and keep others safe?
What considerations need to be taken into account with regard to young person’s living environment?
Other?
Level of Urgency
Is the report required urgently?
Reason for urgency:
Yes
No If Yes date report required by
Please note: If reports are required urgently for Court or FGCs, we require as much notice as possible (at least 6 weeks). We will do our best
to meet urgent requests but reserve the right to say no if we do not have the resource at the time. Our normal process is to run a waiting
list. Youth Assessments are completed within 12 weeks of the first appointment session.
Wellington Region Referrals
PO Box 45-109, Waterloo, Lower Hutt
Phone 04 566-4745 or Fax 04 569-5556
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Family Information
Mother’s Name:
Mother’s Address:
Father’s Name:
Father’s Address:
Mother’s Phone (Home):
(Work):
(Cell):
Father’s Phone (Home):
(Work):
(Cell):
Current Caregivers:
Telephone (Home):
(Work):
Date of Placement (if relevant):
Details of Sexually Harmful Behaviours
Details of Sexually Abusive/ Harmful Behaviour (include duration and number of times if known):
Was coercion or force used?
Yes
No
Don’t know
Where did the sexually harmful behaviours happen?
Sexual Abusive/ Harmful Behaviours (Online referrals- highlight boxes; Paper referrals- tick boxes)
Anal intercourse/ attempted anal intercourse
Oral/ genital contact
Vaginal intercourse/ attempted vaginal
Digital penetration
intercourse
Makes victim touch offender’s genitals
Penetration with an object
Masturbates in front of victim
Touches victim’s breast/ genitals
Sexual abuse of animals
Frottage/ rubbing genitals on victim
Indecent exposure/ flashing
Voyeurism/ peeping
Stealing underwear
Indecent phone-calls/ mail
Not known
Child pornography
Other (describe)
Who was harmed (Names, ages, relationship to client):
Attitude of client’s family to the sexually abusive/ harmful behaviour:
Family accepts what is alleged
Family does not believe what is alleged
Family wants help for their young person
Family is blaming others for what happened
Family is upset by what has happened
Family is minimising what happened
Family supports their young person to face up
Other:
Young person’s description of their sexually abusive/ harmful behaviour:
Wellington Region Referrals
PO Box 45-109, Waterloo, Lower Hutt
Phone 04 566-4745 or Fax 04 569-5556
CONFIDENTIAL
2
Young person admits to the behaviour:
Young person wants to change behaviour:
Yes
Yes
No
No
Don’t know
Don’t know
Prior history of sexually harmful behaviour:
Were substances used during sexually abusive/ harmful behaviour?
Alcohol:
Yes
No
Don’t know
Drugs:
Yes
No
Don’t know
Type of drugs used:
Evidence of Young Person’s alcohol and/ or drug consumption
Details of other Harmful Behaviours
Prior history of any other offending:
Please give details if known:
Yes
No
Don’t know
Self-Harming Behaviour:
Suicidal ideation/ attempts:
Please give details if known:
Yes
Yes
No
No
Don’t know
Don’t know
Violent and Aggressive Behaviours:
Please give details if known:
Yes
No
Don’t know
Safety Concerns
Any Siblings and Other Children Living with Client
Name
Age
1
2
3
4
5
6
Family are providing adequate supervision:
Yes
Gender
Living with client
M
F
Yes
No
M
F
Yes
No
M
F
Yes
No
M
F
Yes
No
M
F
Yes
No
M
F
Yes
No
No
Don’t know
Is there a safety plan in place?
No
Wellington Region Referrals
PO Box 45-109, Waterloo, Lower Hutt
Phone 04 566-4745 or Fax 04 569-5556
Yes
Don’t know
?
?
?
?
?
?
(Attach copy)
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Adverse Childhood Experiences
Has young person experienced any of the following traumatic experiences (Please give details if known)
Emotional Abuse
Yes
No
Don’t know
Physical Abuse
Yes
No
Don’t know
Sexual Abuse
Yes
No
Don’t know
Emotional Neglect
Yes
No
Don’t know
Physical Neglect
Yes
No
Don’t know
Loss of parental figure
Yes
No
Don’t know
Witnessed domestic violence
Yes
No
Don’t know
Alcohol and Drug Issues in family
Yes
No
Don’t know
Mental Health Issues/ Suicide in family
Yes
No
Don’t know
Criminality in family
Yes
No
Don’t know
Other Behaviours/ Issues of Concern
Intellectual Disability:
IHC or other services involved:
Please give details if known:
Yes
Yes
No
No
Don’t know
Don’t know
Mental Health Issues or Diagnoses:
Yes
No
Don’t know
Please give details if known (eg ADHD, depression, conduct disorder, anxiety) and any medication
prescribed:
Attachment Issues:
Yes
No
Don’t know
Please give details if known (eg insecure or broken, multiple placements):
Traumatic Experiences:
Yes
No
Don’t know
Please give details if known (eg abuse, witnessing violence, death of close relative):
Parental Issues:
Yes
No
Don’t know
Please give details if known (eg inconsistent parenting, harsh parenting, illness, financial and other
stressors):
Wellington Region Referrals
PO Box 45-109, Waterloo, Lower Hutt
Phone 04 566-4745 or Fax 04 569-5556
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Other Behaviours of Concern:
Please give details if known:
Yes
No
Don’t know
School/ Education or Employment
Current School/ Employer:
Since:
Contact Person:
Role:
Phone:
Fax:
Are they aware of this referral:
Yes
No
Don’t know
What (if any) sexual behaviours does client display at the educational/ employment setting?
School Issues:
Yes
No
Don’t know
Please give details if known (eg other behavioural problems, learning problems, truancy, suspension,
expulsion, multiple changes of school):
GSE Involvement
Yes
GSE contact person:
Email:
No
Don’t know
Young person has a positive relationship with school:
Young person attends school regularly:
Family are involved with the young person’s school:
Phone:
Yes
Yes
Yes
No
No
No
Don’t know
Don’t know
Don’t know
Young Person’s (YP) Strengths (Highlight or tick boxes if you know that the Young Person / family has
these strengths)
YP has positive talents and interests
YP has some problem solving skills
YP has some communication skills
YP has at least one good friend
YP experiences consistent, positive
YP has support from family and/ or
parenting
others
Family Strengths
Family have good support network
Family are positive about their YP
Family have good communication skills
Family have spiritual beliefs
Family involved with community
organisations (e.g. clubs, church)
Wellington Region Referrals
PO Box 45-109, Waterloo, Lower Hutt
Phone 04 566-4745 or Fax 04 569-5556
Family is protective towards the YP
Family have clear rules and boundaries
Family will bring the YP to WellStop
Family are positive about their culture
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Medical
Current GP:
Phone:
Are they aware of this referral:
Fax:
Yes
No
Don’t know
Yes
Yes
Yes
No
No
No
Don’t know
Don’t know
Don’t know
Significant Medical History:
Legal Status
CYFS Care & Protection Involvement:
CYFS Youth Justice Involvement:
FGC Held or Pending:
Date:
FGC Outcome (Attach Summary of Outcome):
CYFS have Custody:
Yes
No
?
Child is a Ward of Court:
Yes
CYFS have Guardianship/Additional Guardianship:
Yes
No
?
Youth Aid/ Police/ Court Involvement:
Contact Person:
Phone:
Email:
Yes
No
Don’t know
No
?
Where is the young person in the Court Process?
Who is the client’s legal guardian/s?
Parents
CYF
Other (give details)
The legal guardian/s is/are aware of this referral and has/have agreed to it:
Yes
No
Previous CYFS Involvement
Brief Summary (Dates, type of involvement, reason, outcome):
Placement History in foster care, family home, Residential Unit etc:
Date/ Year
Placement
Caregivers
Outcome
Wellington Region Referrals
PO Box 45-109, Waterloo, Lower Hutt
Phone 04 566-4745 or Fax 04 569-5556
CONFIDENTIAL
6
Significant Other Contact People
CYFS Social Worker:
Address:
Email:
CYFS Supervisor:
Address:
Email:
Other (State):
Address:
Email:
Other (State):
Address:
Email:
Other (State):
Address:
Email:
Phone:
Phone:
Phone:
Phone:
Phone:
Other Agencies Involved
Agency:
Key Person:
Phone:
Reason Referred:
Agency:
Key Person:
Phone:
Reason Referred:
Outcome:
Outcome:
Agency:
Key Person:
Phone:
Reason Referred:
Agency:
Key Person:
Phone:
Reason Referred:
Outcome:
Outcome:
Reports Supporting this Referral
Please attach where possible
o Evidential Interview Reports
o Police Summary of Facts
o Full history of previous Police involvement
o CYFS reports outlining history of involvement
o Victim statements or interview summaries (if appropriate)
o Other relevant reports (psychiatric, psychological, educational, medical)
Wellington Region Referrals
PO Box 45-109, Waterloo, Lower Hutt
Phone 04 566-4745 or Fax 04 569-5556
CONFIDENTIAL
7
How will the Assessment be Funded:
For most Child, Youth and Family Service referrals the assessment costs will be covered by a CYF
National or Regional Contract. The exception to this is if there are no places available on the CYF
National or Regional Contract.
In these instances a funding approval form will be provided for signing by the CYF Service Manager.
For all other referrals, please contact us to discuss funding options and assessment costs.
Please forward this referral form, relevant information and funding approval form to:
Casey Williams, Youth and Children’s Team, Wellington
Ph (04) 566-4745 ext 829 [email protected]
Or post to PO Box 31316, Lower Hutt, 5040
Or Fax to (04) 569-5556
Wellington Region Referrals
PO Box 45-109, Waterloo, Lower Hutt
Phone 04 566-4745 or Fax 04 569-5556
CONFIDENTIAL
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