Referral Form

The fields marked with an asterisk are compulsory and must be filled to successfully submit this referral form.

If you need help to complete this form, please call the QPASTT Duty Officer on (07) 3391 6677

Referral Form

Referral Source

Self-Referral
Self-Referral - referral source

Consent is essential for all QPASTT Services

Is there client consent for QPASTT to contact this person?
Has the parent/s consented to this referral if the person is under 18 years?
Can client be contacted directly?
We cannot accept a referral without consent.

Please provide other contact details

Person Referred (Client)

Gender
Interpreter Required:
Visa Status
Client has been in Immigration Detention

Referral Information & Indicators (Will be used to determine eligibility and triage accordingly)

What is the reason for referral?
Please tick and describe is any of the following are present:
Are you referring other family members for Family Counselling?

ADD FAMILY MEMBER

Does this person consent to the referral?
Consent is required to refer other family members.

Trauma, Health and Disability Information. Select at least one.

A possible question to ask about torture and trauma is "some people have had bad things happen to themselves and their families. Has anything happened to you or your family that is affecting the way you are feeling now?"
Adults/Adolescents/Children
Additional considerations for Children/Adolescents only
Learning difficulty/cognitive Impairment?
Physical disability and/or chronic illness?

Supports

Please provide details of any other workers/agencies supporting this person and the type of support provided (other than the referring agency). Include NDIS.
Maximum upload size: 25MB
Would you like to receive a copy of this form?
Separate multiple emails with commas (,) (e.g. person1@mail.com, person2@mail.com)