Youth Program Referral Child/Applicant InformationFamily Name* Given Name* Date of Birth* MM slash DD slash YYYY 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 InformationIs the young person under a current care order with the Minister? No Yes Territory Families Case Manager Guardian name Relationship to child Work PhoneHome PhoneMobileAddress Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Referrer InformationAre you (the referrer) the young person's guardian?* No Yes Referrer Name Referrer Organisation Referrer Email Referrer PhoneApplicant/Child Medical DetailsKnown allergiesDietary restrictionsDate of last tetanus injection MM slash DD slash YYYY 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 LimitationsDoes 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 managedSubstance Use DetailsWhat 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 requiredRisk 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 InformationIs 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. ConsentAs parent/guardian of the applicant, I give permission for the following… my child to attend therapeutic program activities on and away from the CAAPS facility CAAPS staff to make appropriate referrals on be half of my child to other services that will enhance my child's participation in CAAPS program. my child to attend appointments or activities with other service providers as part of their participation in CAAPS programs staff to contact other agencies and request information concerning my child staff to provide daily care and direction to my child as part of the residential program staff to seek medical attention in case of illness/accident whilst in the program my child to be treated by paramedics and transported to Royal Darwin Hospital if required. staff to administer first aid and medication if required my child to attend medical appointments and under take treatment whilst in the program my child to attend and undertake dental treatment required whilst at CAAPS my child to undertake pathology testing (e.g. blood test) if required by a doctor my child to undertake both Oral and Urine Drug Screening, if deemed necessary. CAAPS staff to assist my child with taking prescribed medication if required. my child to be provided with Paracetamol for temporary pain relief my child to be given appropriate Immunisations, if required in order to ensure they are up to date the client to attend program activities on and away from the CAAPS facility the client to participate in swimming activities under the supervision of staff staff to transport clients in CAAPS vehicles the client to attend overnight camps away from CAAPS facility Guardian Name 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.Child Name 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 CAPTCHA
