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Client Details:
First Name: Last Name:
State: Post Code:
Postal/Shipping Address:
Click if As Above
Post City:
State: Post Code:
Client Details:
DOB: Indigenous Status:
Gender: Country of Birth:
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
Phone: Mobile:
 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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Date: Mon, January 20, 2020 For: Crisis Hours Time: 30  Edit
Notes: Case closure for this client as she does not reside in the area.

Date: Wed, December 4, 2019 For: Arranging Referrals Time: 30  Edit
Notes: Creating client file, updating database and spreadsheet. No further action at this stage. Referred to Bre pending further contact by client. LG

Date: Wed, December 4, 2019 For: Individual Counselling Time: 30  Edit
Notes: Sat with Shirley and friends to discuss supports in the South Burnett area to support Shirley with ongoing DV issues. Shirley mentioned that she is only here for a few days and will return home. Additional contact numbers provided such as life line and DV Connect.

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Add Referral
Date: Wed, December 4, 2019 Action Reqired: No  Edit
Memo: Self Referral - Shirley Brodie - 04.12.19. LG
Document:  View Document >>  

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