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1 Grattan Ct, Wanniassa ACT 2903
(Located behind Police and
Community Youth Club in Wanniassa)

(02) 6296 8900

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- Employment
Group programs
News
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Services
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Referral for Case Management form

Client Details

Name *

Address *

Phone *

Other Phone *

Email *

Gender *

Male
Female
Transgender

DOB *

Current Age *

Identity *

Aboriginal
Torres Strait Islander
Aboriginal and Torres Strait Islander

Where is your mob/clan from? *

Preferred Language *

Other family members please include dates of birth

Name

DOB

Name

DOB

Name

DOB

Name

DOB

Name

DOB

Name

DOB

Name

DOB

Name

DOB

Name

DOB

Name

DOB

Any further information *

Employment Status *

Fulltime
Part-time
Casual
Student
Not Employed

Education Level *

Employment Preparation
Engaged w/ Education
Not Engaged w/ Education
Other
Training

Household Composition (copy) *

( Example: living with partner/living alone/alone with children )

PRIMARY REASON FOR REFERRAL

PLEASE SELECT 3 ONLY (NUMBERING THEM 1-3 IN PRIORITY OF NEED)

Housing/Homelessness

Parenting Support

Culture

Prenatal / Postnatal Support

Care and Protection

Financial Issues/Concerns

Out of Home Care

Family/Domestic Violence

Lack of Support

Bullying

Socially Isolated

Anger Issues

School Issues

Youth Justice

Employment

Police/Criminal Matters

Advocacy

Relationship Issues

Alcohol and Other Drugs

Life and Social Skills

Mental Health

Self Esteem

Social and Emotional

Suicidal Tendencies/Self Harm

REFERRAL

Self-referral *

Yes
No

Referring Agency / Organisation *

Contact Person *

Phone *

Email *

Type of assistance being provided *

Other organisations involved with the client *

Realistic Outcomes *

Do you have the client’s permission for this referral? *

Yes
No

Is there any other information you think we should know about the client and their current situation? *

Email

PLEASE DIRECT ALL COMPLETED REFERRAL FORMS TO:

Amanda Savle

Deputy Director

Gugan Gulwan Youth Aboriginal Corporation

Po Box 307, Erindale Centre ACT 2903

amanda@gugan-gulwan.com.au

Phone: (02) 62968900 Fax: (02) 62319933

*Referrals to individual staff members is not permitted

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Location

1 Grattan Ct, Wanniassa ACT 2903
(Located behind Police and
Community Youth Club in Wanniassa)

Gugan Gulwan operates
Monday to Friday from 9am to 5pm

Contact

(02) 6296 8900

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