Family referral form

I will have ongoing involvement with this young person/family

Street Address

Gender Select…ManWomanNon-BinaryTrans ManTrans WomanPrefer not to sayPrefer to self-describe

Pronouns

I need an interpreter

Language of interpreter

Where should the bereavement pack be sent? Direct to client at above addressTo referring health professional

If the client is a sibling, what is their date of birth?

Has the individual agreed to be contacted by Redkite?* YesNo

Summary of situation and support needs

What support is required? Emotional supportFinancial supportPractical support

Privacy statement & declaration of consent

Redkite respects our client’s right to privacy. In order to determine eligibility for assistance and provide this service, we need consent to collect, store and use the client’s personal information, including sensitive information such as health details. Here are a few things we’d like you to know about the way Redkite handles private data.

Privacy statement

The personal information provided here is collected, stored and used by Redkite in accordance with the Australian Privacy Principles and our Privacy Statement to determine eligibility, provide services and send Redkite communications to clients and other members of their family. We may also seek participation in relevant research and evaluation involving personal information. For further information on the way Redkite manages and uses personal information please refer to the Redkite Privacy notice here.

Declaration of consent

Your signature declares that verbal consent has been obtained from the person being referred and the person has consented to their contact details and other personal information being collected, stored and used by Redkite for the purposes specified in this document, and this has been recorded in your case notes. If submitted by fax, you are required to physically sign this form. If submitted online, you are not required to physically sign this form as long as we receive a valid email signature with your full name, title and hospital details.

I agree to and accept the Terms & Conditions*