Remote Youth Program Referral Child/Applicant InformationLast Name* First Name* Date of Birth* DD slash MM slash YYYY Gender* Male Female Intersex Culture* Aboriginal Torres Strait Islander Aboriginal & Torres Strait Islander Preferred Language* Applicant Mobile Number Community* Has the young person previously attended CAAPS* Yes No Parent/Guardian InformationIs the young person in the care of the Minister?* Yes No Parent/Guardian Name* Relationship to Applicant Phone NumberSubstance Use DetailsWhat substances is the young person using?*How often does the young person use substances?* Daily Weekly Monthly Rarely Referral InformationWho is making the referral?* Myself Family/Friend Organisation Are you over 16 years of age?* Yes No As you are not over 16 years of age, you will need a Parent/Guardian or Referral Service to complete this form.Referring Service* Contact Name* Contact Number*What is the reason of the referral?*ConsentI give CAAPS permission to take photos and videos of me during the Youth Remote Program* Yes No I give permission for the following:* I agree to participate in the Youth Remote Program I authorise my details be collected and stored by CAAPS and Government databases for reporting purposes I give CAAPS permission to take photos and videos of my child during the Youth Remote Program* Yes No As parent/guardian of the applicant, I give permission for the following* I have been given information about this referral and agree for my child to be referred to the CAAPS Youth Remote Program I hearby authorise information regarding my child's background to be collected and stored on the CAAPS and Government databases for reporting purposes only As the Referral Service, I confirm the Parent/Guardian of the applicant have given permission for CAAPS to take photos and videos during the Youth Remote Program* Yes No As a Referral Service, I agree to the following:* We have provided information regarding the Youth Remote Program to the applicant as well as their Parent/Guardian The Parent/Guardian have authorised for the applicants details be collected and stored on CAAPS and Government databases for reporting purposes CAPTCHA
