Human Nature Referral Form

Thanks for your interest in Human Nature. Please complete this referral form and we will be in touch.

Human Nature is not a crisis response service

For mental health emergencies please call the Mental Health Line 1800 011511. The Mental Health Line is available to everyone in NSW and operates 24 hours a day, 7 days a week.

Emergencies:
If someone has attempted, or is at immediate risk of attempting to harm themselves or someone else, call Triple Zero (000) immediately. Or go to a hospital emergency department, where they may refer you to a mental health service.

Eligibility: Human Nature participants are:

Between the ages of 14 and 18,
Living in the following locations:
*Ballina Local Government Area
*Byron Local Government Area,
*Tweed Heads
*Murwillumbah, or
*within 40kms of Ballina.
Presenting with significant challenges (e.g. trauma, addictions, mental health issues, social problems, behavioural difficulties or family conflict/breakdown), and
Experiencing barriers to engaging with support in clinical settings.

Young Person's Details:

First Name *

Last Name *

Preferred Name

Date of Birth *

Town and Country of birth: *

Young Person's Address

Street *

Suburb *

State *

Postcode *

Phone Number

Email address:

Parent/Carer Details:

Relationship to young person: *

First Name: *

Last Name: *

Address: *

Phone number *

Email address:

Who is referring?

Referral Source *

If you are from a referring service, please provide your details here:

Name:

Organisation name:

Your position title:

Phone number:

Email address:

Consent:

Is the Parent/Carer aware of this referral? *

YesNo

Has the young person consented to this referral? *

YesNo

Additional Information:

Young person's sex *

Young person's gender

Specify Gender (if not listed above)

Young person's pronouns:

Information about any disabilities, neurodivergence or learning difficulties:

Please list any medications the young person is currently taking:

Who does the young person live with? What is their relationship (mother, father, sibling, uncle, etc)? Other members in the household and ages:

Please provide contact details of any other support people for this young person that would be useful for us to know about (eg. school supports, therapists, case managers, etc.):

Education and Employment:

School/Education Name if currently enrolled:

What is the young person's level of engagement?

Employment details if relevant:

Concerns:

Please provide a brief outline of concerns: (Include mental and physical health concerns) *

Duration of concerns:

Any current and/or previous mental health diagnoses/treatment (by whom/dates/medications):

Any past or current contact with Police and/or criminal justice system? If no, type N/A, If yes, provide details *

Goals:

If 'Other" add goals here:

Resilience Factors:

Please describe some of the positive things that support their wellbeing:

Personal qualities:

Friends:

Parents/carer relationship:

Enjoys:

Good at:

Risk Factors:

If "Other" please provide information here:

Please describe any ways the young person and/or their family have been impacted by the recent floods *

Human Nature's Services:

Please indicate the young person's level of comfort in the outdoors: *

What assistance would you like from Human Nature? *

Please provide any suggestions for activities the young person would enjoy in engaging with our staff eg drawing, music, fishing, basketball, bush walking, kicking a football:

Detail any known risks for outreach service delivery including home visiting and transporting young person:

Does the young person have a preference for a male or female therapist?

MaleFemaleNo PreferenceNot sure

Does the young person have a preference for a male or female therapeutic mentor?

MaleFemaleNo preferenceNot sure

Anything else you think it would be important for us to know about the young person?

Financial contributions and fees:

We are a not for profit organisation, and so we require contributions for program costs where possible, but recognise that many of those we work with are struggling financially and may not have the means to contribute. Therefore session fees can be discussed on a case-by-case basis, and no-one will be excluded due to inability to pay.

If you indicate you have capacity to make a contribution, our Program Manager will be in touch to discuss this with you once the referral has been accepted.

Please choose one option: *

I have the capacity to pay for the service as per our fee scheduleI'd like to discuss my financial capacity with the Program Manager

Comments:

What happens next?

Thank you for your referral to Human Nature. We will be in touch with you within the next 2 weeks.

If you have any questions about this referral or our programs please give us a ring on 0477 176 312, email office@humannature.org.au or check out our website https://www.humannature.org.au

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