CareSouth Youth Hostel Referral Form

Agency Details

Agency Name

Phone Number

Caseworker

Caseworkers Phone

Young Persons Details

Young Persons Name

Date of Birth

Gender

Male

Female

Phone Number

Mobile

Current living arrangements (with whom, for how long)

Has this person stayed at the Youth Hostel before?

Yes

When did this person previously stay at the hostel?

Medical Information

Any medical conditions

Ongoing prescribed medication

Background

Any background of drug abuse, alcohol abuse, gambling or inhalant abuse?

Yes

Please Comment

Counsellor Name

Counsellor Phone

Does the young person have any police charges?

Yes

Next court date

Charge Detail

Juvenile Justice Worker Name

Phone No

It is sometimes necessary for CareSouth Youth Hostel to contact other services and previous accommodation providers in order to verify information.

Does the young person give permission for CareSouth Youth Hostel to make those contacts?

Yes

Is there any information you would like to add?

I confirm to the best of my knowledge that the above information is correct.