Client Referral Form - Melaleuca Refugee Centre
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2Client Referral Form
People eligible to access Melaleuca Refugee Centre (MRC) Programs and Support for Torture and Trauma
services include adults, children, young people and families who have a refugee or asylum seeker background, a
history of torture and trauma prior to arrival in Australia, are newly arrived young people at risk of homelessness
and who are experiencing psychological or psychosocial difficulties believed to be associated with their
experience of torture and trauma.
Please email referrals to the Team Leader of the counselling team at
.au
1. CLIENT CONSENT:
Client consent is essential for all referrals to MRC Programs.
Is there client consent for MRC to contact client?
YES / NO
Can the client be contacted directly?
YES / NO
2. REFERRAL SOURCE:
Date: _____/_____/________
Referring Organisation: ____________________________________________________________
Name of Worker: ___________________________
Tel: ______________________________
Mobile: _________________________________ E-mail: ______________________________
3. CLIENT INFORMATION:
Family Name: ___________________________________________________________ Gender: M / F
Given Names:_________________________________________________ Date of Birth:___/___/___
Address: ___________________________________________________________________________
Telephone: _____________________ Mobile: ____________________ Best time to phone: AM / PM
Country of Origin: __________________________________ Date of Arrival: ____________________
Ethnicity: _______________Preferred Language/s: ________________Interpreter Required: YES / NO
For clients under 18 years of age - Parent/Guardian details:
Consent to
Name
Address
Phone Number
service provision
Does the young person give permission to
Yes
No
Maybe later
contact their family?
Living arrangements: Please indicate any other family members that reside with the client and their relationship to the client:
Migration status: Refugee / Woman at Risk/ Special Humanitarian/ Visa 866/ BVE/ other: __________
(Please circle)
Previous Detention Centre/s: ___________________________________________________________
[1]
24 McLachlan Street, Darwin NT 0800 • PO Box 1930, Darwin NT 0801 • Tel: (08) 8985 3311 • Fax: (08) 8985 3322
Email: .au • Web: • ABN: 50 116 495 405
15/08/2016
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