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 SOURCEReferring 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,) ______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 NOCultural Identity of person being referred:______Country of Birth: ______Preferred Language: ______Interpreter Required: YES NOVisa 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 NOIf yes, please elaborate: ______Please specify main income source for example Youth Training Allowance, Austudy, Disability Support Pension etc:______SERVICE USER INFORMATIONPlease 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 INFORMATIONPlease 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 accommodationAccommodation Type Length of Stay Reasons for MoveDHS 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:________________________Family History:  (Consider: Current/past relationships, reasons for family break down, family dynamic ) ____________________________________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 ____________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) ______________________________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______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 NODoes 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) ______________________________ What is the purpose for drug and alcohol taking (Consider patterns of usage, why and when used, feeling prior to usage).________________________Cultural Beliefs Are there any cultural practices or spiritual beliefs that we need to be aware of (Consider Religious beliefs, customs, festivals etc)?______________________________Coping Skills:  (Consider: Strategies to deal with emotion regulation and behavior management.) ____________________________________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) ____________________________________Forensic/Legal Issues:  (Consider: Imprisonment, past & pending legal matters, community based orders, outstanding fines, supports) ____________________________________Strengths  (Consider: Personal strengths in relation to , ability to manage challenges that have or could occur.) ____________________________________Hobbies & Passions:  (Consider: Interests, recreation, activities of interest.) ____________________________________Future Plans:  (Consider: Future endeavors, hopes & dreams etc.) __________________________________________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:____________________________________Current Supports:  (Consider: Family, Friends, Agencies, Education, Employment.) ______________________________Any other information? : ______________________________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.______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

Lighthouse Foundation Service Assessment Form

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