YPS SHS Intake Form

• Document No.

• Audit Title

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

Young Person Basic Information

• Date:

  Yes

  No

  N/A

• Name

  Yes

  No

  N/A

• Date of birth:

  Yes

  No

  N/A

• Current address (if applicable)/ mailing address?

  Yes

  No

  N/A

• Contact number:<br>Contact email:

  Yes

  No

  N/A

• Country of Birth?

  Yes

  No

  N/A

• Cultural identity(eg Aboriginal, Torres Strait Islander, Anglo etc):

  Yes

  No

  N/A

• Does the yp have any literacy issues- eg learning challenges, can't read, difficulty completing forms etc?

  Yes

  No

  N/A

• Referral source? (Self, agency, friends?)

  Yes

  No

  N/A

• Has the yp been connected with YPS in the past?

  Yes

  No

  N/A

• Does the young person have any children? Are they in their care? Is there any FaCS involvement?

  Yes

  No

  N/A

Income and ID

• Is the yp on a Centrelink benefit?

  YA

  IYAR

  ABS

  DSP

  other- specify

• Fortnightly income:

  Yes

  No

  N/A

• Is the yp employed:

  Yes

  No

  N/A

• What type of ID does yp have: eg Birth Certificate, Photo Card, Drivers License, Medicare Card, Bank cards; Paasport; Tax File Number etc

  Yes

  No

  N/A

Homelessness & Housing status

• Identified presenting issue- what's happening at the momen?

  Yes

  No

  N/A

• Where is yp currently staying? What type of property? (Eg house, unit, caravan, rough sleeping?)

  Yes

  No

  N/A

• Who else lives there?

  Yes

  No

  N/A

• Is the yp's name on lease where they are staying at the moment?

  Yes

  No

  N/A

• Is the yp paying board or some type of rent where they are currently staying? How much?

  Yes

  No

  N/A

• Has the yp rented before? Do they have rental references?

  Yes

  No

  N/A

• Has the yp ever been evicted from a property? Are they on TICA?

  Yes

  No

  N/A

• Time since last permanent address? (How long since they have lived somewhere permanently?)

  Yes

  No

  N/A

• Has the yp completed/ submitted HNSW application?

  Yes

  No

  N/A

Other issues & existing supports

• Is the yp connected to any other services?

  Yes

  No

  N/A

• Does the yp have existing or previous mental health issues?

  Yes

  No

  N/A

• Has the yp ever been, or currently, connected to FaCS or DJJ?

  Yes

  No

  N/A

• Is the yp engaged in education (school, TAFE, short courses)?

  Yes

  No

  N/A

• Does the young person have access to School Reports?

  Yes

  No

  N/A

• Does the yp identifying any existing support people in their life, eg parents, friends etc?

  Yes

  No

  N/A

• Does the yp give permission for YPS to contact existing case workers/ support workers?

  Yes

  No

  N/A