YPSP Nomination webform

Young person's details

1. Name(Required)

First Last

2. Mobile(Required)

3. Email(Required)

4. Preferred contact method(Required)

Phone
Email
Text

5. Date of birth (dd/mm/yyyy)(Required)

6. Current address(Required)

7. Cultural identity(Required)

8. Gender(Required)

Male
Female
Gender diverse

8a. If gender diverse, please provide more detail(Required)

9. Preferred pronouns

10. Is a Legal Guardian involved?(Required)

Yes
No

10a. If yes, what is their name(Required)

10b. If yes, what is their phone number(Required)

11. Is a Public Trustee involved?(Required)

Yes
No

11a. If yes, what is their name(Required)

11b. If yes, what is their phone number(Required)

12. National Disability Insurance Scheme (NDIS) participant?(Required)

Yes
No
Currently applying to the NDIS

12a. If NDIS participant, please confirm primary diagnosis(Required)

12b. What conditions, learning difficulties or allergies do you have?(Required)

Referrer's details (if not young person)

13. Name

First Last

14. Relationship with young person

15. Position

16. Organisation

17. Phone

18. Mobile

19. Date (dd/mm/yyyy)

20. Has the young person agreed to this referral?

Yes
No

21. How long (months / years) have you known the young person?

Young person's support details

22. Do you have any current supports in place?(Required)

Yes
No

22a. If yes, please indicate(Required)

22b. Please provide support contact details, if known:(Required)

23. Do you have any current informal supports?(Required)

Yes, family
Yes, friends
Yes, community
No

24. Have you been or in the process of being referred to any other services?(Required)

Yes
No

24a. If yes, please provide details(Required)

25. What type of supports are you looking for as a part of this program?(Required)

Young person's preferences

26. Do you want someone to assist you at the meet and greet session?(Required)

26a. Name of support person (Peer Worker), if known:

26a. Name of support person (family / friend), if known:

26a. Name of support person (Aboriginal Liaison Officer), if known:

26a. Name of support person (other), if known:

27. Do you want your parent or Guardian to also sign the consent and participant agreement forms?(Required)

Yes, Parent
Yes, Guardian
No

27a. If yes, name of Parent or Guardian(Required)

Youth wellbeing CAT assessment form

To be completed by young person and/or support person with consent.

28. Date (dd/mm/yyyy)(Required)

29. Name of person/s who completed this form(Required)

First Last

30. Name of young person(Required)

First Last

31. Name of support person/ Peer Worker(Required)

First Last

The CAT uses a 1 to 5 scale. The values of scale are:
1 = Can be a lot better
2 = Can be better
3 = OK (but can be better)
4 = Doing well
5 = Doing great
Please tick the applicable number and the priority checkbox if the domain is a priority for you.

32. Domain: My housing(Required)

32a. What is your current housing situation?(Required)

33. Domain: My schooling or work & income(Required)

33a. What is your current participation in school or work / income?(Required)

34. Domain: My family relationships(Required)

34a. What is the current situation with your family relationships?(Required)

35. Domain: My social connections(Required)

35a. What is the current level of your social connections with peers?(Required)

36. Domain: My physical health(Required)

36a. What is your current health situation?(Required)

37. Domain: My drug and alcohol use(Required)

37a. What is the impact of your substance use on your current well-being?(Required)

38. Domain: My mental health(Required)

38a. What is your current mental health situation?(Required)

39. Domain: My culture (if relevant)(Required)

39a. What is your current level of cultural connection?(Required)

Write n/a if not applicable.

40. Domain: My parenting and children (if relevant)(Required)

40a. What is your current parenting situation?(Required)

Write n/a if not applicable.

41. Domain: My disability (if relevant)(Required)

41a. What is your current disability situation?(Required)

Write n/a if not applicable.

42. Domain: My involvement with the law (if relevant)(Required)

42a. What is your current involvement with the criminal justice system?(Required)

Write n/a if not applicable.

43. Domain: My desire / motivation to make changes(Required)

43a. How motivated are you to achieve change across relevant domains?(Required)

44. Domain: My belief in my capacity to make changes(Required)

44a. How confident are you of your ability to achieve change across relevant domains?(Required)

Please submit your Information Consent form, Participant Agreement form and Risk Assessment form

Please submit the Information & consent form, Participant Agreement form, and Risk Assessment form here. Please contact ypsp@pillar.org.au or (08) 6253 4700 if you have any issues.

45a. Information Consent file submission(Required)

Drop files here or

Max. file size: 512 MB.

45b. Participant Agreement file submission(Required)

Drop files here or

Max. file size: 512 MB.

45c. Risk Assessment file submission

The risk assessment needs to be completed by the referring agency or service provider. If you are referring yourself, please contact Pillar to complete the form with you.

Drop files here or

Max. file size: 512 MB.

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YPSP Nomination webform

Nomination Web Form Submission - Youth Psychosocial Support Packages

Young person's details

Referrer's details (if not young person)

Young person's support details

Young person's preferences

Youth wellbeing CAT assessment form

Please submit your Information Consent form, Participant Agreement form and Risk Assessment form

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