Please let us know how to contact you and continue to fill the following where relevant/as best as able.

Relationship to Contact --Select-- Helping Professional (i.e., School Counsellor, Social Worker) Parent/Caregiver (ie., Father, Mother, Grandparent, Relatives, Guardian, Sibling)

Name of Person who Enquired

Organization (programme)/School You Are Referring From (if applicable)

Contact Number of Enquirer

Email of Enquirer

Has the youth / child consented to this referral? --Select-- Yes No

Is the youth/child aware of the information (e.g., mental health concerns, safety concerns) you will be disclosing to us? --Select-- Yes No

Youth/child's Responsiveness to Services --Select-- Low Moderate High Not Applicable

Parent/Caregiver's Responsiveness to Services --Select-- Low Moderate High Not Applicable

Is there active non-suicidal self-injury (NSSI) behaviours? --Select-- Yes No Unsure

Indicate youth's/child's methods, frequency, alternative recommended to NSSI behaviours (if applicable)

Does the youth/child has active suicide ideation? --Select-- Yes No Unsure

Indicate risk level, past attempts, and deterrents (if applicable)

Is the parent/caregiver aware of youth/child's active suicide ideation? --Select-- Yes No Unsure

Does the youth / child has a safety plan? --Select-- Yes No Not Applicable

Has the youth's parent/caregiver consented to the referral? --Select-- Yes No

If you require updates, please elaborate updates required

Identified youth's asset(s)/interest(s)

Hopes of youth in general or for this referral

Hope of caregiver in general or for this referral

Recommended Referral Arrangements --Select-- Contact Parent aregiver Directly Contact Youth Directly Joint Session Referral Link up