Lighthouse Foundation Service Assessment Form

Lighthouse Foundation 13 Adolph Street Richmond Vic 3121 Phone: (03) 90937500 Fax: (03) 90937555 Lighthouse Foundation Referral Form Date:

REFERRAL SOURCE

Referring Agency: (if applicable): ______

Name of Person Making Referral: ______

Contact No: Fax No: Email:

Name of Person being referred: ______Date of Birth: ______Age:___

Young Persons Preferred Contact: ______

Family aware that Person is seeking support: Y / N

Preferred Home/Homes: (Kensington, East Malvern, Richmond, Ballarat, Clayton, Springvale, Bonbeach, Boronia,)

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Would the young person consider another area? ______

Any area the young person would not consider? ______

Does the person being referred identify as Aboriginal or Torres Strait Islander origin? YES NO

Cultural Identity of person being referred:______

Country of Birth: ______Preferred Language: ______

Interpreter Required: YES NO

Visa status/Type(If applicable):______Gender: Male: Female: Other:

Are there any sensitivities or issues regarding sex, sexuality and/or gender that the young person would like us to know about? YES NO

If yes, please elaborate: ______Please specify main income source for example Youth Training Allowance, Austudy, Disability Support Pension etc:______

SERVICE USER INFORMATION

Please Note: Lighthouse Foundation is committed to providing all service users with quality service and maintaining individual’s privacy and confidentiality. If an agency is making a referral the young person’s permission to disclose the information is required.

______Consent given: YES / NO (please circle yes or no and attach consent to Release Information Form)

Document name: Lighthouse Foundation Referral Form Version: 3.0 Document Created: 2009 Last Reviewed: July 2016 Next Review: July 2017 Approval Authority Director of Care Services BACKGROUND INFORMATION

Please consider in relation to the young person’s past and present situations.

Accommodation History/ Current Accommodation take into consideration:

 Length of homelessness  Previous accommodation types  Number of and reasons for breakdowns  Current accommodation  Reasons seeking supported accommodation

Accommodation Type Length of Stay Reasons for Move

DHS Involvement: History with DHS: Y / N, Protective Order: Y / N, Guardianship Order: Y/N, Custody Order: Y / N

** If the young person is currently on an order, approval from DHS Placement Coordination Unit is usually required before sending this referral through. Approval to be faxed or emailed through**

Additional Notes:______

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Family History:  (Consider: Current/past relationships, reasons for family break down, family dynamic ) ______

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Abuse:  (Consider: sexual, physical, emotional, neglect and/or exposure to the previous mentioned) ______

______

Document name: Lighthouse Foundation Referral Form Version: 3.0 Document Created: 2009 Last Reviewed: July 2016 Next Review: July 2017 Approval Authority Director of Care Services ______

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Education/Employment:

 (Consider: Level of education, employment history, current situation)

______

 Is school/employer aware of the current situation? Yes No

General Health  (Consider: Current concerns, diagnosis, regular medication, hospitalisations, dental, any known allergies etc) ______

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Mental Health  (Consider: Diagnosis, hospitalizations, support from other agencies.) ______

______

Please specifiy______

 Does the young person have a Community Treatment Order YES NO

 Has the young person undertaken any mental health assessment in the previous year? YES NO

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Document name: Lighthouse Foundation Referral Form Version: 3.0 Document Created: 2009 Last Reviewed: July 2016 Next Review: July 2017 Approval Authority Director of Care Services  If required can we receive a copy of this report? YES NO

Does the young person have an intellectual disability or impairment? Yes No

Drug and Alcohol:  (Consider: Drugs used – past and present, detox/rehab, methadone/buprenorphine, supports – past & present) ______

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 What is the purpose for drug and alcohol taking (Consider patterns of usage, why and when used, feeling prior to usage).

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Cultural Beliefs

 Are there any cultural practices or spiritual beliefs that we need to be aware of (Consider Religious beliefs, customs, festivals etc)?

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Coping Skills:  (Consider: Strategies to deal with emotion regulation and behavior management.) ______

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Risk Behaviors: ______

Document name: Lighthouse Foundation Referral Form Version: 3.0 Document Created: 2009 Last Reviewed: July 2016 Next Review: July 2017 Approval Authority Director of Care Services  (Consider: Violent behaviours, patterns of self harm, frequent absconding) ______

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Forensic/Legal Issues:  (Consider: Imprisonment, past & pending legal matters, community based orders, outstanding fines, supports) ______

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Strengths  (Consider: Personal strengths in relation to , ability to manage challenges that have or could occur.) ______

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Hobbies & Passions:  (Consider: Interests, recreation, activities of interest.) ______

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Future Plans:  (Consider: Future endeavors, hopes & dreams etc.) ______

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Document name: Lighthouse Foundation Referral Form Version: 3.0 Document Created: 2009 Last Reviewed: July 2016 Next Review: July 2017 Approval Authority Director of Care Services Expectations from Lighthouse:

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Current Supports:  (Consider: Family, Friends, Agencies, Education, Employment.) ______

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Any other information? : ______

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Genogram:

A genogram (pronounced: jen-uh-gram) is a graphic representation of a family tree that displays detailed data on relationships among individuals. It goes beyond a traditional family tree by allowing the user to analyze hereditary patterns and psychological factors that punctuate relationships. Genograms allow a therapist and his patient to quickly identify and understand various patterns in the patient's family history which may have had an influence on the patient's current state of mind. The genogram maps out relationships and traits that may otherwise be missed on a pedigree chart.

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Document name: Lighthouse Foundation Referral Form Version: 3.0 Document Created: 2009 Last Reviewed: July 2016 Next Review: July 2017 Approval Authority Director of Care Services