Youth Development Referral Form
Please provide as much detail as possible on this form when you are referring a young person onto
the 12 week youth development course. It helps us assess whether the course is appropriate for their
needs, and allows us to adjust our support as relevant for each young person.
Young Person Details
Name:
Gender?
Date of birth:
Address:
Phone number:
Email:
Referral Agency Details
Referral Agency:
Type of Agency:
Name(s) of worker(s):
Address:
Contact no:
Email:
Does the young person have any other workers allocated to them from different agencies? If Yes
please give details:
Background Details about the Young Person
Reason for Referral
Why do you wish to refer the young person to the 12 week development programme?:
Youth Development Referral Form
CRICOS Provider No 00092B TAFE South Australia RTO Code: 41026
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Current Situation
Employment status (tick as appropriate):
Not working at all
Working 16 hours or less per week
week
Working more than 16 hours per
If yes which days do they work?
Education status (tick as appropriate):
Not in education
In education or training less than 12 hours per week
12 hours or more per week
In education or training
Offending Background
Not applicable
If the young person is an offender please give the following details:
Details of last offence (and any unspent conviction):
Was the offence/ unspent conviction:
against children
Serious violence
Arson
Sexual offence
Offence
Date of last conviction:
Length of sentence:
Number of prison sentences:
Is there a risk of the young person re-offending?
Yes
No
If yes, please rate level of risk :
Medium High
Custody Details
Low
Not applicable
Prison name:
Prisoner number:
Earliest date of release:
Contact address on release?
Is the young person on Home Detention Curfew, or will they be on release
Yes
No
Offending Behaviour
Not applicable
Youth Development Referral Form
CRICOS Provider No 00092B TAFE South Australia RTO Code: 41026
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Has the young person been in trouble with the police (ie never been convicted but has been getting in
trouble and starting to enter the criminal justice sector?)
What are the concerning/ at risk behaviours?
Family Situation and Social Services
Not applicable
What is the young person’s housing situation?
What is the young person’s family situation?
17 Year olds:
Please give details of any social services involved with the young person?
Is the young person under the Guardianship of the Minister?
Does this young person have a current I.E.P (individual Education Plan)
18 years and over:
Please give details of any social services involved with the young person?
Mental Health Needs
applicable
Not
Please give details if the young person has any mental health needs:
Medical Health Needs
applicable
Not
Please give details if the young person has any medical health needs:
Youth Development Referral Form
CRICOS Provider No 00092B TAFE South Australia RTO Code: 41026
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Disabilities
applicable
Not
Please give details if the young person has a disability:
Learning Needs
applicable
Not
Please give details of educational needs/special needs/learning difficulties etc and/or problems with
reading, writing or maths:
Rating level of educational support need:
Medium
High
Low
Addiction Issues
applicable
Not
Does the young person have any issues with the below?
Drug use. Please give details:
Alcohol Use. Please give details:
Any Other Issues
Not applicable
Is there anything else you think we should know? (e.g. membership of gang, anger management
issues, victim of bullying, perpetrator of bulling, bereavement, debt issues etc)
I understand that the information collected compliances with the Government of South Australia's
information privacy principles (IPPs) it will form part of the young person’s file and if the young person
requests to see information that TAFE SA holds on them, under the Act, we would release this
information. More detailed information can be found in the TAFE SA Privacy Policy and Procedure
Youth Development Referral Form
CRICOS Provider No 00092B TAFE South Australia RTO Code: 41026
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Signed ...........................................................................
Date .............................................................................
Please email the completed forms back to me directly. Any further questions you can contact me on
the details below:-
Debbie McGrane
Youth Hub Coordinator
Regency Park Campus
137 Days Road
TAFE SA Regency Campus , 5010
T 08 8348 4030
E Debbie.McGrane@tafesa.edu.au
W tafesa.edu.au
Youth Development Referral Form
CRICOS Provider No 00092B TAFE South Australia RTO Code: 41026
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