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Client Details:
First Name: Last Name:
Address:
Address:
City:
State: Post Code:
Postal/Shipping Address:
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Address:
Address:
Post City:
State: Post Code:
Client Details:
DOB: Indigenous Status:
Gender: Country of Birth:
Language:    
School:  
Living Arrangements: Child Protection Client Status:
Source Of Referral: Client Service Type:
Reason For Referral: Client Group:
Referral Date: dd/mm/yyyy Closed Date:
Counsellor: Reason for Closure:
Unprogressed: Drop-In:
Pre-School: Consent for Govt to Contact:
Highest Schooling: Receiving Centerlink?
Marital Status: Active?:
       
Who Received Service:  Client  Partner  Family  Friend  Parent/Carer
Contacts:
Phone: Mobile:
Email:
Comments:
Disabilities:
 Intellectual / Learning     None
 Not Stated / Inadequately Described     Other
 Physical / Diverse     Psychiatric
 Sensory / Speach 
Other Identified Issues:
 Aggressive Behaviours     Anger
 Anxiety     Attachment Disorder
 Bullying     Criminal Involvement
 Depression     Dissociation
 Domestic Violence     Drug / Alcohol Misuse
 Eating Disorder     Employment Problems
 Financial     Flashbacks
 Grief     Housing
 Interpersonal Relationships     Isolation
 Loneliness     Low Self-Esteem
 Mistrust     Nightmares
 Parenting Skills     Phobias
 Poor Impulse Control     Post - Trauma
 Problematic Sexual Behaviours     Revictimisation
 School Problems     Self Harming Behaviour
 Sexual Dysfunctions     Sexuality
 Sexually Abusive Behaviours     Sleep Disturbances
 Somatic Complaints     Suicidal Ideation / Behaviours
 Witness to Domestic Violence 
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Client Status:
 Improved Life Skills  Support Still Required
Therapeutic Interventions:

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Referrals:

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Memos:
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