RiverTracks Referral Expression of Interest Form
After reading our referral information pack (available on our website) please complete this form to express interest on behalf of a young person who may like to be part of the RiverTracks program.

We request that if possible the parent or caregiver completes this form but otherwise someone else may complete the form on their behalf.

As you fill out this form you will need to type something in response to every question in order to be able to move on through the form. If you don't have an answer to a question you can simply type any letter in the box and move on.

The information that you provide will help us better understand the young person’s likelihood of getting benefit out of participating in the program. We need accurate information to work out the suitability of each applicant. Please be as open as possible in answering the questions in this form.

The RiverTracks is a voluntary program for all participants. By this we mean that is important that young people are choosing to attend. It is important to understand that due to the nature of the program young people cannot be forced into attending, they must decide if they want to participate themselves.

The information we ask you to provide in this form assists us in assessing whether the program is right for applicants.

CONFIDENTIALITY: The information provided here will be respected as private and will not be shared outside our organisation without your permission.

Thanks for taking the time to provide this information on behalf of your young person.

Ahri Tallon
Youth Worker and Operations Manager
Email: ahri@rivertracks.org
Enquiries: 0493 206 791
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Name of person completing form:
Role of the person:
Clear selection
Email:
Mobile:
Relationship to young person being referred:
Name of parents/carer:
*If this form is not being completed by them.
Email of parents/carer:
Mobile of parents/carer:
Parent/carer gender:
Clear selection
Address of parents/carer:
Does the young person have permission from their parents/carer to be referred to the RiverTracks program?
Clear selection
Name of the young person: *
Date of Birth *
MM
/
DD
/
YYYY
Gender *
Does the young person identify as Aboriginal or Torres Strait Islander? * *
Is the young person interested in learning more about the RiverTracks program? *
Please detail the level of school the young person has been attending recently and historically? *
Does the young person have any physical/intellectual disability? If yes, please give details. * *
Does the young person have any special cultural/spiritual/religious, language or communication needs? (If yes, please specify) *
Is the young person attending school and if so which one? *
What life challenges is this young person facing currently? *
Please provide detail.
Does the young person have any sexual behaviour issues or concerns? *
Does the young person have any history of and or present violent behaviours? *
Does the young person have any history of and or present drugs and alcohol usage? *
Does the young person have any history of and or present mental health challenges? If so please give details regarding the suspected causes, severity and what they are experiencing. *
Are there any existing criminal convictions that may be a cause for concern for the safety of other program participants? Please provide details if so. *
Is the young person in contact with a Police Youth Liaison Officer? *
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Is the young person currently being supported by any existing youth support services? If so, please give details as to who and how. *
Why do you think the RiverTracks program may be able to help this young person? *
What are the young person's strengths? *
What does the young person enjoy? *
Has the young person been given information about the RiverTracks program already? *
Are there any barriers to the young person participating in RiverTracks? E.g. homelife, transport, *
Does the young person live in the Murwillumbah or Tweed Valley area and has accessible transport to Murwillumbah on weekdays? *
Are there any other comments or information you would like to share?
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