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Balaa Youth Mentoring Referral
Youth Mentoring Referrer Details
Referrer Name
Staff Member
Contact Number
Email Address
Child or Young Person’s Identifying Information
Name
Date of Birth
DD slash MM slash YYYY
Age
Gender
Nationality
Aboriginal
Torres Straight Islander
Non Indigenous
Other
If the child or young person is Aboriginal and/or Torres Strait Islander, what is the child or young person’s nation(s)/tribe(s)?
Young Person's Likes and Dislikes
Does the Young person know about the referral and if so, what are their views toward mentoring?
Parent Caregiver Details
Carer Name
Carer Phone
Carer Address
Legal Status
Legal Status
No Court Orders
Restoration Children’s Court (NSW)
Guardianship Children’s Court (NSW)
Interim Children’s Court (NSW)
Long term care Children’s Court (NSW
Family Law Court (Aust)
Other
If Other, give details
Details of Referral
Proposed Start Date
DD slash MM slash YYYY
End Date
DD slash MM slash YYYY
Frequency of Sessions
Start Time
Finish Time
CYP Pickup Address
CYP Dropoff Address
Estimated Travel Time per Session
Estimated Number of Kilometres per session
Medical or behavioural concerns?
Reasons for Referral?
Suggested Venues/Locations
Goals?
Other information relevant to support service delivery?
Attachments (if any)
Max. file size: 128 MB.
Attachments (if any)
Max. file size: 128 MB.
TERMS and CONDITIONS
a. In the event that the referrer cancels, recalls or suspends a Request for Services Form after 2:00pm the day before, the referrer will pay the Service Provider a sum equivalent to 3 hours of the staff rate for the applicable Service Type. No fee in respect of transport costs will be payable.
b. A minimum engagement period per mentoring event of 3 hours, including 1 hour report writing time applies for each mentoring referral.
c. Any fees or cost associated with of lateness on the part of a client, carers or parents, or other Service Provider, will be payable by the referring service.
d. Report will be available to the referrer within 48 hours of the event where requested.
e. All accounts are payable within 14 days of invoicing, multiple events will be invoiced monthly.
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