CIYEP Referral

Cairns Indigenous Youth Empowerment Program

Refer someone to CIYEP

Use this form to refer a young person to CIYEP. You can refer yourself, a family member, or someone you support. A CIYEP worker will review the referral and be in touch within 2 business days. If it's an emergency, please call 000.

How urgent is this referral?

Low — no immediate concerns

Low

Medium — needs follow-up this week

Medium

High — needs response within 24–48 hours

High

Crisis — safety risk now

Crisis

About you (the referrer)

So we know who to contact about this referral.

Your full name *

Relationship to the young person

Your role / title

Organisation (if any)

Phone *

About the young person

The person you'd like to refer.

Full name *

Preferred name

Date of birth

Gender

Phone (if known)

Language(s) spoken

Address

Suburb / community

School / employer

AboriginalTorres Strait Islander

Parent / guardian or next of kin

Required if the young person is under 18.

Name

Relationship

Phone

Reason for referral

What's been happening? What help is the young person looking for?

Presenting issues (tick any that apply)

Alcohol & other drugsMental health / wellbeingJustice / contact with policeHousing / homelessnessFamily & relationshipsEducation / school engagementEmployment / trainingCultural connectionOther

Describe what's been happening *

What outcomes are you hoping for from CIYEP?

Risk flags

Let us know about any safety concerns so we can respond appropriately.

Risk of self-harm or suicideRisk of harm to others / violenceChild safety concernsIn crisis right now

Notes about any risks

Other supports already involved

Other agencies / workers involved

Existing case manager

GP / health worker

NDIS participantReceiving Centrelink

Consent & sign-off

I confirm I have the young person's (and where applicable, their guardian's) permission to share their details with CIYEP for the purpose of this referral.

Preferred contact method

Best time to make contact

Your signature (type full name) *

Date *

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