Youth Referral Form - Anchor Community Care Ltd

Referring Organisation

Name*

Organisation*

Role*

Contact Number*

Email*

Young Person

Name*

Date of Birth*

Age*

Current Address*

Housing Type

Housing Type (Other)

Phone

Gender*

Country of Birth

Aboriginal or Torres Strait Islander*

Yes

Main Language

Cultural Identity

Eligibility Criteria

Aged between 16-21*

Yes

Lack of stable income to support housing education*

Yes

Please describe the young persons current housing and family situation and how this impacts on their education*

Connection to Lilydale*

Yes

It is important students are familiar with Lilydale and the local area and to be able to access shops, medical services, public transport, community activities and employment.

How well does the young person know Lilydale and what are their connections to Lilydale and the surrounding area?*

Stable income*

Yes

Living at the foyer requires students to live independently, this means paying 25% of their income in rent and supporting themselves financially.

Does the young person receive Centrelink payments, if so what payments do they receive?

Do they have a job or other source of income?

Demonstrate personal stability*

Yes

A requirement of the Youth Foyer is that young people with mental health or AOD concerns must be able to manage these effectively so they can maintain their education, employment, home and participate in the program.

Does the young person have any concerns about their mental health?*

Have they been diagnosed with a mental health condition? If so please provide further information?*

What supports do they have to help them and how do they manage this? (medication, safety plan, strategies)

Do they have any concerns about alcohol or drug use?*

What supports do they have to help and how do they manage this?

Willing to engage in education, employment, and training?*

Yes

The Lilydale Youth Foyer is an education program that supports young people to engage in or maintain their education and career goals. Young people are encouraged and supported to access employment, to provide them with skills, experience and the financial means to live independently.

If the young person is currently a student what course are they studying, where and what year level?

Are they motivated to enrol in education and what would they like to study?

What are their education goals for the short term and long term?

Does the young person currently have employment, if so where and what role?

If not currently working, what industry are they interested in working in? (both long term and short term)

Motivated to participate in the Foyer Life and Living Skills program and willing to be a member of the Lilydale Foyer community*

Yes

Is the young person wanting to further their life and living skills and in what skills would they like to work on?

Does the young person feel comfortable in group settings and able to participate in group discussions and activities?*

Who are the key supports for the young person

Support One

Name*

Number*

Role / Organisation / Relationship*

Support Two

Name

Number

Role / Organisation / Relationship

Support Three

Name

Number

Role / Organisation / Relationship

This field is for validation purposes and should be left unchanged.