Referral Form

If you need help to complete this form, please call the STTARS Intake Officer on (08) 8206 8900

We prefer to receive electronic referrals through the form below, however, if you cannot complete an electronic referral, you can also complete this PDF form and return to us through the details provided.

The fields marked with an asterisk are compulsory and must be filled to successfully submit this referral form.

Referral Source

Date
Self Referral 
Has the person being referred consented to this referral? 

We cannot accept a referral without consent

Self-Referral - Referral Source 
Other Referrer
Address

Consent is essential for all STTARS Services

Can client be contacted directly? 
Is the person being referred under 18 years? 
Is this person
Has the parent/guardian consented to this referral 
Please provide other contact details
Are there any safety concerns for this person?
Are these safety concerns current or past?

Person Referred

Date or Year of Birth
Gender 
Address

e.g. contact after 2pm; send SMS before calling; do not leave voicemail?

Having some background information will help us to tailor our services better

Interpreter Required 
Interpreter preferences
Ethnicity

Multiple ethnicities can be included

Does this person self-identify as LGBTIQA+?
Residency Status
Has this person been in Immigration Detention?
Length of time in immigration detention 
Experienced Statelessness

Stateless people are those who have been denied the right to nationality and not been recognised as citizens in any country.

Referral Information & Indicators
(Will be used to determine eligibility and triage accordingly)

STTARS provides services for people how have experienced torture, violence and/or significant trauma in the context of war, political upheaval or refugee flight.

Please tick and describe if any of the following are present:

Trauma, Health and Disability Information. Select at least one.

A possible question to ask about torture and trauma is "some people have had bad things happen to themselves and their families. Has anything happened to you or your family that is affecting the way you are feeling now?"

Adults/Adolescents/Children
Additional considerations for Children/Adolescents only
Service requested 
Learning difficulty/cognitive Impairment?
Physical disability and/or chronic illness?

Supports

Please provide details of any other workers/agencies supporting this person and the type of support provided (other than the referring agency). Include NDIS.

Agency details

We cannot accept a referral without consent