Close
Everything we do here at YIRS is free and confidential.
72 Victoria Street
Mackay QLD 4740
Call Us Today
(07) 4957 7949
Email Us
ua.gr
1714147948
o.sri
1714147948
y@nim
1714147948
da
1714147948
Home
About
Services
Support
Medical Help
Major Sponsors
Contact Us
Refer Us
Donate
Referral Form
Home
Referral Form
"
*
" indicates required fields
1
Referral Agency Details
2
Client Details
3
Consent
Referral agency:
*
Referral agency contact person/details:
*
Name:
*
Position:
Client Details:
*
First
Last
Date of Birth:
*
DD slash MM slash YYYY
Address:
*
Contact Number:
Mobile:
Support or Contact Person:
Support or Contact Person Number:
Cultural Identification:
Aboriginal
Australian South Sea Islander
Torres Strait Islander
Aboriginal and Torres Strait Islander
Others
Others:
Presenting Concerns:
Youth Justice
Medical
Family
Centrelink
Child Protection
Education/Training
Young Parent
Substance Misuse
Accommodation
Employment
Mental Health
Relationships
Legal Issues
Pregnancy
Others
Others:
Consent Form Attached:
Yes
No
Consent Form:
*
Max. file size: 16 MB.
If no please give reason:
Reason for referral:
Contact with other agencies/organisations:
Surname:
Given Name/s:
I acknowledge that YIRS has advised me about:
some information will be recorded about me that a service can provided
I have the right to privacy and confidentiality
I can ask to see the personal information recorded about me
Information will not be shared with others without my consent (except for duty of care reasons, as explained to me)
I can withdraw my consent at any time.
Consent to collect and disclose
*
I understand that YIRS may need to collect and disclose personal information to third parties in order to provide me with support. I nominate that my personal information be disclosed only to the right person/s or agencies listed below:
*
This consent relates to the following specific personal information of type of information:
I consent to the stated personal information being discussed with /released to the following organisations and/or individuals:
*
I consent to the stated personal information being released to / discussed with the nominated organisations or persons for the following purpose/s:
*
I consent to the stated personal information being released to / discussed with the nominated organisations or persons for the following purpose/s:
*
Aware Withdraw Consent
*
I am aware that I may withdraw this consent, or part of it, at anytime by telling YIRS that I do not consent to further release of information about me.
*
