This form is to be completed in full when applying to have a client/young person admitted to
BushMob V.S.A/A.O.D Residential Treatment Facility. A through assessment can only be made if
all information required on this form is true and correct and filled in fully and all other assessment
(Medical, Mental Health etc.) that have been made on the client/young person are also attached.
Date of Referral: _______________
Referral Information
Client/Young Person’s Name: _______________________________________________________
Date of Birth: _______________
Age: _____________
(Please Circle) Male
Female
Medicare Number: _____________________________ CRN: _____________________________
Client Address: ___________________________________________________________________
____________________________________________________________________
Language: Spoken English
Understood English
Aboriginal Language
Is the Client aware/accepting of this referral? ___________________________________________
School attendance for school-aged Clients is a requirement of BushMob.
Is the Client willing to attend school? _________________________________________________
Referral Agency Involvement
Agency Name: ___________________________________________________________________
Workers Name: ___________________________________________________________________
Landline: _____________________________
Mobile: ______________________________
Current and projected Client status: __________________________________________________
Is the Client aware of the referral and if so how do they feel about being referred for treatment?
______________________________________________________________________________
Are you as the referring person willing to explain the referral process and give the client relevant
information about the 16 week BushMob program prior to them arriving should they be accepted?
(Please circle) Yes No
Family History: ___________________________________________________________________
____________________________________________________________________________
Biological parents: ________________________________________________________________
Current guardian: _________________________________________________________________
Please list all siblings including customary, step or foster siblings
Name
Age
Lives Where
1
Lives With
Extended Family
Maternal: ______________________________________________________________________
Paternal: ______________________________________________________________________
Languages spoken: ______________________________________________________________
Education
When was last attendance at school? _______________________________________________
Name of school: _________________________________________________________________
Highest grade completed: __________________________________________________________
Did / does Client like Sschool? ______________________________________________________
Relationships
Who does your Client live with? ______________________________________________________
How does your Client get along with family members? ___________________________________
Who does your Client feel closest to? _________________________________________________
Who are his/her closest friends? ______________________________________________________
Does your Client talk to any Elder’s, if so who? __________________________________________
Is there a girlfriend or boyfriend? _____________________________________________________
Medical History
Does your Client have any medical problems? (Please identify and send any medical attachments).
Doctor or medical service details and contact numbers:
2
Is your Client currently on any medication? (State what it’s for, the type of medication and frequency):
Does your Client have any allergies?
Legal Issues
Is your Client currently on probation or on a Court Order (please outline the nature of the offence and
charges) or under a Child Protection process?
(Please include length of time and dates)
Community Corrections case officer name: _______________________________________________
Worker Name: ______________________________________________________________________
Landline: __________________
Mobile: _____________________
Fax: ____________________
DCF Case Worker Name and Region: ____________________________________________________
Landline: _________________
Mobile: ____________________
Fax: __________________
Is DCF aware of the referral, and are they willing to support the referral?
___________________________________________________________________________________
___________________________________________________________________________________
3
Probation or Child Protection Order
Conditions:
Copy attached:
Yes
From: __________________
To: ___________________
No
Alcohol and Other Drug including Inhalants Use History
At what age did your Client start sniffing? ____________________________________________________
At what age did your Client start alcohol? ____________________________________________________
At what age did your Client start using other drugs? ____________________________________________
Has your Client ever used any of the following?
Substance
Petrol
Yes
No
Glue
Paint
Other Inhalants and
Solvents /Aerosols
Marijuana
Alcohol
Amphetamines
Speed
Opioids,Heroin,
Morphine, Methadone
MDMA, Ecstasy
Minor Tranquilisers
Valium, Rohypnol,
Serepax
Caffeine
Other
4
How long?
Does anyone else in the family use solvents/substances? :
Yes
No
What solvents/substances are used? _____________________________________________________
Does your Client use solvents/substances on their own or with others? ___________________________
Place
At home
A friends Place
School
Abandoned building
Other
Yes
No
Place
Town camp
Remote community
At a party
Outside
CBD
Has your Client got into physical fights when using solvents /substances? Yes
Yes
No
No
Has your Client ever caused serious injury to others? Please elaborate.
Does your Client have any medical, physical, psychological, emotional problems because of the use of
solvents/substances? Please elaborate and attach relevant reports.
Does your Client feel he/she is in control of his/her solvent/substance use? ________________________
Has your Client ever considered reducing or quitting? ________________________________________
Has your Client ever been in any previous treatment for use of solvents/substances? _________________
Where? _______________________________________________________________________________
When? ______________________________________________________________________________
Psychological Functioning
Has your Client ever spoken about killing himself/herself? ___________________________________
Has your Client ever attempted to kill himself/herself? _______________________________________
How many times? ___________________________________________________________________
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Has your Client gone off on his/her own when depressed/unhappy? ____________________________
Does your client every say they hear voices? _______________________________________________
Is your Client currently sad/ unhappy? ____________________________________________________
Is there any known history of sexual, physical or emotional abuse?
Please explain i.e. at what age, has it been reported and what is the current status:
When the Client is in a Sober State
Has he/she reported communicating with spirits no one else can see or hear and how often has this
happened?
_________________________________________________________________________________
Have these been positive or negative experiences for the Client/young person:
__________________________________________________________________________________
Has your Client had any Psychiatric /Psychological/Cognitive testing or counselling?
(If yes please identify and send any medical attachments and documentation):
Outside Resources
What other agencies are involved with your Client and his/her family?
If so, which ones and what services do they provide?
Status in the community: (How is the family perceived in the community?)
6
Yes
No
What type of belief system is practiced? ___________________________________________________
How does the Client spend his/her leisure time? _____________________________________________
Is the Client/family aware of the effects of solvent/ substances?
Yes
No
Does the family believe that the Client recognises his/her problem? What steps does the family want to take
to address the problem and are they supportive of treatment?
Has anyone else in the Clients family received treatment for solvent/substance abuse?
Upon completion of the program, what type of support system do you see as effective /useful to help
maintain a clean lifestyle for the Client?
Would some Family be willing to come to the BushMob facility to see what is offered?
State significant losses or Sorry Business or areas that may be affecting the Client related to unresolved
grief.
7
Referring Agency/persons Recommendations
Please indicate what areas of healing you feel that we should concentrate on?
Is there any additional information that your Client or family feels would contribute to your Client’s
treatment?
8