Aftercare Program Referral Home » Aftercare Program Referral BrightPath Care Services - Aftercare Program Referral Form (Supporting young people transitioning to independent living) Date of Referral: Referral Details Referral Type (please tick): Self-referralNGODepartment of Communities and Justice (DCJ)Other If referred by someone other than the client, has the referrer obtained the client’s consent? YesNo (Consent must be obtained before proceeding) Is this referral supported with documentation? Final Care Order:YesNo Endorsed Leaving Care Plan (LCP): YesNo Financial Summary:YesNo Client Details Full Name Preferred Name: Preferred Pronouns: Date of Birth: Age: Gender: MaleFemaleOther Contact Details: Residential Address: Postal Address (if different): Are you of Aboriginal or Torres Strait Islander descent? AboriginalTorres Strait IslanderBothNeither Cultural Identity / Ancestry: Main Language Spoken at Home: Is an interpreter required? YesNo Do you have children of your own? YesNoPregnant Out-of-Home Care (OOHC) History ChildStory Number: Last DCJ Office: OOHC Case Management Agency: Caseworker Name & Contact Details: Did your Final Care Order confirm you were under the Parental Responsibility of the Minister until 18 years? YesNo Has a Leaving Care Planning meeting been scheduled? YesNo Is there an endorsed Leaving Care Plan for you? YesNo Current Circumstances Current Living Situation: Independent LivingTransitional HousingHomeless or At Risk of HomelessnessFoster PlacementSupported AccommodationResidential CareTemporary Accommodation Do you pay rent? YesNo Length of time at current address: How long can you stay there? Do you require housing assistance? YesNo Are you on the DCJ Housing waitlist? YesNo Do you have an AHA or T-Number? YesNo What is your capacity for independent living? No support requiredRequire some supportRequire significant support Income and Employment Main Source of Income: Salary / WagesCentrelink BenefitsNo IncomeOther Current Employment Status Employed (Full-Time)Employed (Part-Time)Employed (Casual)Unemployed, Looking for WorkUnemployed, Not Looking Gross Weekly Income: Have you ever had a job? YesNo Outstanding Bills or Debts: YesNo Education Highest Level of Education: Primary SchoolHigh SchoolTAFE Certificate or DiplomaUniversity Degree Currently Enrolled in Education: YesNo Health and Wellbeing Medical Check in Last 12 Months? YesNo Dental Check in Last 12 Months? YesNo Eyesight Tested in Last 12 Months? YesNo Mental Health Diagnosis: YesNo Prescribed Medications: Disability Status: YesNo NDIS Package: YesNo Application in Progress YesNo Legal and Safety Criminal History or Pending Legal Cases: YesNo Any AVOs Involving the Client: YesNo Use of Alcohol or Drugs: YesNo Support Needs How can we help you?
