Rural Youth Mental Health Referral Form

This form is designed to be completed by or with the young person requesting support from the Rural Youth Mental Health team. Please note that Rural Youth Mental Health is a voluntary program, consent from the young person is required for the referral to be completed.

Rural Youth Mental Health is not an emergency or crisis program, Rural Youth Mental Health works with young people experiencing mild to moderate mental health challenges who might be feeling anxious, depressed, have low self-esteem, difficulty managing emotions, having trouble sleeping, experiencing bullying or relationship challenges.

Eligibility

Rural Youth Mental Health service supports young people aged between 12 and 25 years who are experiencing mental health challenges like early warning signs of anxiety or depression, or are concerned about their mental health. A mental health diagnosis is not required.

If there are immediate safety concerns please contact 000, present to the local hospital, or contact the mental health line on 1800 011 511.

Consent

Consent* - required

REFERRAL DETAILS

Referral Details

Date of Referral

Referral Completed by* - required

Referrer Phone* - required

Referrer Email* - required

Organisation Name (if applicable)

Client Details

Name* - required

Address* - required

Date of Birth* - required

Phone* - required

Gender

Pronouns

Aboriginal or Torres Strait Islander

Language spoken at home

Country of birth

Mental health diagnosis (if applicable)

Disability diagnosis (if applicable)

Any other medical diagnosis' (if applicable)

Carer Details/ Emergency Contact

Name* - required

Address* - required

Phone* - required

Relationship to young person

Does the client give consent for this nominated carer to be contacted in an emergency by the RYMH team?

Aboriginal or Torres Strait Islander

Do you consent for RYMH to contact carer?

Mental Health Support

What is happening for you at the moment, what are your mental health concerns? (Consider mood, managing stress, emotions and anger, sleep, risk taking, sense of hope and purpose, relationships, bullying).* - required

What goals do you want to achieve from working with the Rural Youth Mental Health program?* - required

Are you currently receiving (or have you recently received) any support for your mental health from a counsellor, psychologist, social worker or psychiatrist? If yes, please provide details about the nature of support received.* - required

Risk

Are you currently having suicidal thoughts? If yes, how often do these occur?* - required

Do you have a safety plan?* - required

Do you currently engage in self harm? If yes, how often does this occur?* - required

Mandatory field(s) marked with *