Referral - Aardvark Music

Referral Form

Aardvark welcomes referrals from supporting professionals, young people and/or parents. Please provide details for the health service/support person the young person is linked with and give consent for them to be contacted in regards to the young person. If being filled out by the referring professional please make sure it is with the young person’s consent and knowledge.

Name:

Address:

Postcode:

Phone No:

Email Address:

Date of Birth:

Age:

Primary Language:

Name of Parents/Guardians/Support person:

Parent/Guardian Mobile No:

Email:

Are you Aboriginal or Torres Strait Islander?AboriginalTorres Strait IslanderNo

Pronouns:She/HerHe/HimThey/Them

Musical Interest/Ability/ Instruments:

Current study commitments (School/tafe/uni/not studying):

REASON FOR REFERRAL:

The Aardvark Program is specifically for young people experiencing adversity. Please outline what the current illnesses/conditions/challenges are and needs of this young person that have promoted this referral:

What is the impact of above on the young person’s daily life? Such as physical, psychological, social, family, education:

What is the young person’s current ability to engage with and work in a group? Please include any information that will help facilitators provide a supportive environment for the young person (including any relevant information on the young person’s communication needs):

Young person’s key strengths, and any other important information:

Hospital/Health Care Organisation linked with:

Name of Referrer/Ongoing Contact:

Agency:

Address:

Phone:

Mobile:

Email Address: