FMHSS Referral Form

Family Mental Health Support Services Referral Form

The Family Mental Health Support Service (FMHSS) at Breakthru provides free, tailored support to help children and young people aged 0–18 and their families navigate life’s challenges and strengthen mental health and wellbeing. Support can continue for up to 12 months.

We focus on helping children and young people build confidence, manage emotions, and develop practical strategies to cope with challenges at school, at home, or with friends. At the same time, we support parents and carers to strengthen family relationships, reduce stress, and feel confident and empowered in their role.

Our Mental Health Support Workers walk alongside families to provide:

One-on-one support for children and young people
Parenting guidance and resources to empower carers
Advocacy and referrals to connect families with the right services

Support is flexible and can be offered at school, in the community, or online - wherever feels most comfortable and practical for the family.

Please note: FMHSS is not a crisis or clinical service.

Referrer Details (you)

Full Name of Referrer *

Role / Relationship to Family *

Organisation (if applicable)

Referrer Contact Number *

Referrer Email Address *

Has this referral been discussed with the family, and have they given consent for us to contact them? *

YesNo

Child / Young Person Details

Child's First Name *

Child’s Last Name *

Preferred Name (if different)

Child’s Date of Birth *

Pronouns (optional)

Street address *

Suburb *

State *

Postcode *

School / Early Learning Centre (if enrolled)

Year Level / Class

Country of Birth *

Cultural Background (Ancestry) *

Main Language Spoken *

Interpreter required? *

YesNo

Does the child identify as: *

If yes, please share their Nation or Country (if known):

Does the child have any diagnosed or suspected mental health or developmental conditions? (e.g. ASD, ADHD, anxiety) *

Does the child have any physical, sensory, or communication needs we should be aware of (e.g. wheelchair access, hearing/vision impairment, speech delay)? *

Is the child currently in statutory care (e.g. foster, kinship, residential care)? *

Yes - Please note: FMHSS is unable to provide direct support to children under the age of 15 currently in statutory care (under the legal care of the child protection system).NoUnsure

Reason for Referral

Please describe the main concerns or challenges for the child/young person and their family, and what kind of support or outcomes you are hoping FMHSS can help achieve: *

Parent / Guardian Details

FMHSS works with the whole family - not just the child or young person being referred. We know that when parents and carers feel supported and confident, they are better able to help their children thrive. To make sure we can involve and support parents effectively, we ask for parent/carer details here:

Parent/Guardian’s Full Name *

Relationship to Child / Young Person *

Date of Birth

Pronouns (optional)

Contact Number(s) *

Email Address

Home Address (if different to child)

Street address

City

State

Postcode

Country of Birth

Main Language Spoken *

Interpreter required? *

YesNo

Cultural Background (Ancestry) *

Does the parent/carer identify as: *

Additional Information

Is the family currently involved with Child Protection services? *

YesNoUnsure

If yes, please provide further information regarding Child Protection involvement: *

Is the child or family currently engaged with any other services (e.g. school counsellor, psychologist, caseworker, NDIS)? *

YesNoUnsure

If yes, please list services and supports involved (including contact information if possible): *

Are there any Parenting or Legal Orders in place (including AVO/DVO)? *

YesNoUnsure

Please upload Parenting or Legal Orders:

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If yes, please briefly describe or attach the orders in place:

Are there any additional risks/safety concerns that we should be aware of?

Is there anything else you’d like us to know?

Please upload any additional relevant documents that may benefit our provision of support (e.g. psychologist reports, behavioural plans):

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Before you submit:

Please take a moment to review your answers and make sure all details are correct. This will help our team process the referral as quickly as possible.

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