Referral to:
Care4U Counselling and Support Centre
From:
Referring agency:	Sunny Beach Community Service
Referrer's name:	Simon Richards
Contact details:	111 111 111
Date of referral: 08/06/201X
Client details:
Name:	Thu Thanh
Date of birth:	30/05/1987
Address:	101 Joshua St, Darwin
Phone number:	0413 413 413
Children: (names and ages)	Nil at present - Thu is currently pregnant; father is Thu's ex-partner Alan.
For assistance with:	counselling
Further information:
Thu's ex-partner, Alan, has been stalking and monitoring her, including asking friends and family to report on where she is and what she has been doing; this started prior to their separation two week ago, but Thu says it is getting worse. His behaviour has become more volatile over the past several months, and Thu says that he is using illicit drugs regularly, with an increase in use since he became unemployed a few months ago. Alan has been verbally abusive but Thu reports no physical violence. Alan and Thu have no children yet, but Thu is several months pregnant. Thu is referred to counselling and GP for experiencing high level of anxiety and sleep difficulties.
Risk assessment:
DFV risk Nil identified At risk At high risk	Child safety risk Nil identified At risk At high risk	Suicide risk Nil identified At risk At high risk

Explain what you have learned about Thu's developmental and/or mental health capacity from her referral form and what you plan to do with this information when you see Thu.