Referral Form

Child/Applicant Information

Family Name*

Given Name*

Date of Birth*

Gender

Male
Female
Intersex

Culture*

Aboriginal
Torres Strait Islander
Aboriginal & Torres Strait Islander

Is an Interpreter required?*

Yes
No

Medicare Number

Health Care Card Number

Guardian Information

Is the young person under a current care order with the Minister?

No
Yes

Territory Families Case Manager

Guardian name

Relationship to child

Work Phone

Home Phone

Mobile

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Applicant/Child Medical Details

Known allergies

Dietary restrictions

Date of last tetanus injection

Is the client medicated?

Yes
No

Medication Name

Medication Dose

Medication Time

Reason for medication

Are there additional medications?

Yes
No

Medication Name

Medication Dose

Medication Time

Reason for medication

Are there additional medications?

Yes
No

Medication Name

Medication Dose

Medication Time

Reason for medication

Are there additional medications?

Yes
No

Medication Name

Medication Dose

Medication Time

Reason for medication

Is the client capable of swimming in deep water unassisted?

Yes
No

How would you describe your child swimming ability?

Can’t swim at all
Can stay afloat in water
Can swim a few strokes

Potential Limitations

Does the client have any medical, psychological or behavioural issues that may impact program attendance? If so please state the issues and describe how the issues are managed

Substance Use Details

What substances is the young person using?*

How often does the young person use substances?*

Daily
Weekly
Monthly
Rarely

Risk Screening

Rate the risk level of each item

0 = No Risk, 1 = Possibly, 2 = Interferes with young person's functioning. Needs help., 3 = Dangerous, Immediate intervention required

Risk of Suicide*

0
1
2
3

Self-harming behaviour*

0
1
2
3

Danger to Others through reckless or impulsive behaviours*

0
1
2
3

Danger to Others due to violent behaviours*

0
1
2
3

Risk of running away*

0
1
2
3

Law breaking behaviours – including being in trouble with the Police*

0
1
2
3

Danger to the young person (e.g. is the young person at risk of being harmed/hurt by someone else.)*

0
1
2
3

Does the young person set fires?*

0
1
2
3

Does the young person hurt animals?*

0
1
2
3

Sexually aggressive behaviour*

0
1
2
3

Other Information

Is there any other information which could assist CAAPS in helping your child participate in the CAAPS program?

Please read and check the following points

Staff supervision is always provided for underage clients during outings and appointments.
All Clients will receive an initial medical consultation as soon after admission as practical
All medications are stored securely on CAAPS premises and staff assist clients with any required medication as prescribed by a medical doctor
Clients will be transported to medical appointments in CAAPS vehicles.
If the client is expected to participate in any activity where they will spend 1 night or more away from CAAPS facility, guardians will be notified where possible prior to the activity taking place.
Staff supervision is always provided during all program activities, however should a client require additional support to participate in activities CAAPS may exclude the client from activities if additional support is not available at the time of the activity taking place.

Consent

As parent/guardian of the applicant, I give permission for the following…

I understand the nature of adventure recreation camping programs and the risks involved. I have discussed the program with staff and clarified any areas of concern prior to signing this consent form.

I give consent for the above named child to attend the adventure recreation camping program. In case of emergency I allow CAAPS staff to seek medical assistance for him/ her.

I understand that if another agency is requesting information regarding the client which does not relate to their current participation in the CAAPS program, staff will request permission from you in writing before providing any information (this excludes statutory information sharing e.g. TF, Mandatory Reporting).

Yes
No

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