VACCA Referral Form
Strong and Deadly Boorais (SDB)
Education Support for Children in Care

Child / Young Person Details
First/Middle Name:	Last Name:
Date of Birth:	Preferred Name:
Client Email:	Client Phone:
Home Address:
CRIS Number:
Court Order Type:
Use your professional judgement to decide if it is safe and appropriate to request the following information. Cultural safety, the right to self-determination, and the purpose of collecting gender-specific information must be considered.
Gender Identity:	☐Female ☐Male ☐Non-Binary ☐Intersex ☐Sistergirl ☐Brotherboy
☐Transgender Female ☐Transgender Male ☐Prefer not to say
☐Self-Describe:
Pronouns:	☐She/Her ☐He/Him ☐They/Them ☐Name Only
☐Self-Describe:

Cultural Information
Cultural Identity:	☐ Aboriginal	☐ Torres Strait Islander	☐ Both	☐ Neither
Country of Birth:
Tribe/Mob: (if known)
Totem: (if known)

Communication Needs
Language(s) Spoken:
Interpreter required?	☐ Yes ☐ No
Communication support required? (e.g. hearing, speaking, reading, or writing)	☐ Yes ☐ No	Details:
Would the client like an advocate / support person?	☐ Yes ☐ No	Details:

Health and Disability
Medical condition?	☐ Yes ☐ No	Details:
Diagnosed disability?	☐ Yes ☐ No	Details:

Education
School:
Phone:	Current Year Level:

Placement Details
Type of placement:	☐ Kinship Care	☐ Foster Care	☐ Residential Care	☐ Lead Tenant
Carer 1	Carer 2 (if applicable)
Name:	Name:
Phone:	Phone:
Email:	Email:

Case Management Details
Case management arrangement:	☐ Contracted	☐ DFFH	☐ Nugel/ACAC
Currently participating in care team?	☐ Yes ☐ No
Agency Contracted Case Manager	Child Protection or Nugel Practitioner
Name:	Name:
Agency:	Branch/Area, Division:
Email:	Email:
Phone:	Phone:

Reason for Referral
E.g. Eligibility, benefit for the child, historical and current involvement with educational supports, engagement with other programs, alignment with care plans and education plans, consultation with relevant professionals including LOOKOUT, consent (when required).

Home / Family Situation
E.g. Recent developments impacting on school engagement, placement stability concerns.

Strengths and Interests
E.g. Strengths, interests at school, home and community.

Referrer Details
Referrer Name:
Organisation/Agency:
Signature:	Date:
Referral endorsed by (optional)
Name:
Role/Organisation:
Signature:	Date:

Application Checklist

Please ensure that all items have been checked before submitting this application:

☐	The child/young person met the eligibility criteria.
☐	The child/young person agreed to the referral.
☐	Child Protection or Nugel/ACAC Team Leader endorsement has been obtained (not required if a carer, family member, school or other community members are making the referral; CP/ACAC endorsement can be obtained during assessment and intake).
☐	All relevant sections of the application form are complete.
☐	Additional information/supporting documentation provided to support application.

Send Applications To

Completed applications are to be sent to sdb@vacca.org. If the referral has been accepted, the VACCA ESCC team will reply with an acceptance letter/email.

If the referral does not meet the Program’s criteria, the VACCA ESCC team will reply with either a request for further information or a letter declining the referral. This letter will outline reasons for not accepting the referral and include information on other options for supporting the child/young person.

Privacy Statement

The personal and health information on this form is collected for the purposes of supplying the VACCA ESCC team with the information required to best support the service. The information collected will only be disclosed to VACCA and used for the primary purpose intended. The information will not be disclosed to any other party unless required by law.

Approval
To be completed by the VACCA ESCC Regional Team Leader in consultation with the VACCA Education Team Program Manager.
Date received:
Checked by intake:	☐ Yes	☐ No
Approval status:	☐ Approved	☐ Not approved
Date applicant advised:
Any further comments: