SSRC Referral Home » SSRC Referral Referral Details Date of Referral: Referring Agency/Department: Name of Referrer: Role/Position: Contact Number: Email Address: Client Information Child/Young Person’s Full Name: Preferred Name: Date of Birth: Age: Gender: MaleFemaleOther Cultural Identity/Background: Aboriginal or Torres Strait Islander: YesNoOther Primary Language Spoken: Interpreter Required YesNo NDIS Participant: YesNo NDIS Number: Current Living Arrangement: At home with familyFoster careResidential careOther Emergency Contact Details Name: Relationship to Child/Young Person: Contact Number: Alternative Contact Number: Reason for Referral Provide a detailed description of the reasons for the referral, including: The goals or outcomes expected from the respite careCurrent family situation and support needsAny immediate concerns or risks Details: Support Needs Does the child/young person have any of the following support needs? (Provide details in the space below for any items selected) Behavioural supportMedical or health needsDisability-related supportMental health supportDietary requirementsOther Details: Risk Assessment Are there any known risks associated with the child/young person? (Complete a detailed risk assessment form if applicable.) Aggressive or violent behaviourHistory of abscondingSubstance useSelf-harm or suicidal ideationAllegations of harm to othersOther Details: Respite Care Details Type of Respite Accommodation Requested Supported Independent Living (SIL)Short-Term Respite CareLong-Term Respite CareOvernight CareEmergency/Immediate Placement Duration of Respite Care One-off careRecurringShort-term placement (up to 6 weeks)Medium-term placement (6-12 weeks)Long-term placement (over 12 weeks) Preferred Start Date: Preferred End Date: Preferred Location: Special Requests or Considerations: Additional Information Provide any additional information that may assist with matching the child/young person to an appropriate placement (e.g., interests, hobbies, routines, preferences). Details
