Child and Family Wellbeing Service (CFWS)

Child & Family Wellbeing Service Online Referral

What is the Child & Family Wellbeing Service?

The Child & Family Wellbeing Service supports children/young person(s) aged 0-18 years. We work alongside families and children/young person(s) who are affected by or showing early signs of mental health concerns. Using a person-centred approach, strengths are identified and built upon to work towards goals and enhance wellbeing.

Support is available within Palmerston/Litchfield, Katherine and Gunbalanya Community.

Primary Caregiver’s Details

Caregiver's Name

Date of Birth

Relationship to Participant/s

Gender MaleFemaleNon-binaryOther

Email Address

Contact Number

Address

Country of Birth

Main Language spoken at home

Ancestry AboriginalTorres Strait IslanderNon-IndigenousNot Stated

Interpreter Required? YesNo

Formal Diagnoses (Mental Health / Physical) NoneYes

If yes, please specify

Participants' Details

Child/ Young Person 1 - Full Name

Child/Young Person 1 Gender MaleFemaleNon-binaryOther

Child/Young Person 1 Date of Birth

Please detail any formal or suspected diagnoses, individual support needs and/or key areas of concern?

Child/ Young Person 2 - Full name

Child/ Young Person 2 - Gender MaleFemaleNon-binaryOther

Child/ Young Person 2 - Date of Birth

Please detail any formal or suspected diagnoses, individual support needs and/or key areas of concern?

Child/ Young Person 3 - Full Name

Child/ Young Person 3 - Gender MaleFemaleNon-binaryOther

Child/ Young Person 3 - Date of Birth

Please detail any formal or suspected diagnoses, individual support needs and/or key areas of concern?

Family situation/key concerns:

Brief Risk Assessment – Referrer to complete for each individual referred (incl. parent/carer)

Source of Information (Can select more than one option) ParticipantReferrerClinical StaffCarer or GuardianTeamHEALTH worker

Other, please specify

Family and Participant Risk Factors (If answering ‘yes’ please provide further details)

Detail individual name/initials in each section as required

Parent/Carer Initial

Child 1 Initial

Child 2 Initial

Child 3 Initial

History of suicide attempt/s or current suicide ideation

Parent/Carer NoYes

Child 1 NoYes

Child 2 NoYes

Child 3 NoYes

Recent traumatic life event

Parent/Carer NoYes

Child 1 NoYes

Child 2 NoYes

Child 3 NoYes

Current misuse of drugs or alcohol

Parent/Carer NoYes

Child 1 NoYes

Child 2 NoYes

Child 3 NoYes

Forensic history

Parent/Carer NoYes

Child 1 NoYes

Child 2 NoYes

Child 3 NoYes

Recent incident involving aggression/violence, incl. family member with DVO or aggressive behaviour etc.

Parent/Carer NoYes

Child 1 NoYes

Child 2 NoYes

Child 3 NoYes

Known use of weapons

Parent/Carer NoYes

Child 1 NoYes

Child 2 NoYes

Child 3 NoYes

Expressing intent to harm others

Parent/Carer NoYes

Child 1 NoYes

Child 2 NoYes

Child 3 NoYes

Preoccupation/hallucinations with violent/paranoid themes/ideas

Parent/Carer NoYes

Child 1 NoYes

Child 2 NoYes

Child 3 NoYes

Inappropriate sexual behaviour

Parent/Carer NoYes

Child 1 NoYes

Child 2 NoYes

Child 3 NoYes

Reduced ability to self-control/self-regulate

Parent/Carer NoYes

Child 1 NoYes

Child 2 NoYes

Child 3 NoYes

Major physical disability/illness (including infectious disease)

Parent/Carer NoYes

Child 1 NoYes

Child 2 NoYes

Child 3 NoYes

Known prejudices – ethnic, religions, other:

Parent/Carer NoYes

Child 1 NoYes

Child 2 NoYes

Child 3 NoYes

Issues with compliance eg appointments, medication. If yes, please detail:

Parent/Carer NoYes

Child 1 NoYes

Child 2 NoYes

Child 3 NoYes

Details relating to any identified risks and/or other identified risk factors

Protective Factors

Person Referring

Relationship to Family

Email Address

Contact Number:

Consent

I consent to this referral/ verbal consent has been gained to complete this referral. I understand that this information will be stored on the TeamHEALTH system and that my details will be de-identified if they are used in reporting. I give permission for TeamHEALTH to discuss this information for the purposes of establishing and receiving supports.

TeamHEALTH uses personal information to assist in the coordination and provision of services. Individuals are not required by law to provide this information or consent to this proposed use and disclosure of information. The information provided to TeamHEALTH will be stored in accordance with the Australian Privacy Principles established under the Privacy Act 1998 (Commonwealth) and Northern Territory of Australia Information Act.

I understand and consent that as part of reporting obligations, the Child and Family Wellbeing at TeamHEALTH may be required to share information with Department of Social Services (DSS), state and territory governments, or another agency contracted to DSS, for verification of eligibility, monitoring of outcomes, IT support, reporting, research and statistical purposes. This may include identifying information about me or my child/ young person(s), including mine and my child/young person(s) full name, date of birth, address, disability status, ancestry, country of birth and main language spoken at home as well as other de-identified information.

I understand that no details about the content of sessions will be included in this reporting. I can request that a pseudonym be used if this is my preference. I am aware that Child and Family Programs at TeamHEALTH are funded by the Department of Social Services through the Family Mental Health Support Service. I understand that the Department of Social Services Privacy Agreement can be accessed at https://www.dss.gov.au/privacypolicy or I can request a copy from TeamHEALTH.

I Consent

In the absence of written consent, verbal consent was gained NoYes

Completing This Form
Please call TeamHEALTH on 1300 780 081 if you need any assistance completing this form.
TeamHEALTH will contact the primary caregiver within two working days of receiving this form.
Thank you for your referral