Referral Form

Please use this form to refer a client or participant to Lost in Books. We aim to be a welcoming and safe community space of creativity, multilingualism and support. We ask the below information to help us understand how best we can support the person you are referring.

Full name of person making the referral*

Phone Number of person making the referral*

Email of person making the referral*

Referring Organisation & Organisation Position*

Please fill in the information for the client you are making the referral on behalf of

Is the person you are referring Under 18?*

Yes

*If yes, please also fill out the 'Parent information' section

Has the person you are referring consented to the referral?*

Yes

Person who is being referred

First name*

Last name*

Email*

Mobile phone number*

Phone number

Date of birth*

Gender*

Street address

Postal Code*

Preferred language*

Reason/s for referral (Please include any information that would be useful in making the referral - length of time in Australia, barriers to accessing programs, skills and strengths)*

What program are you referring to?*

If other* please explain

Parent / Guardian Information

Parent/Guardian First Name

Parent/Guardian Last Name

Parent/Guardian Contact Number