I am a parent/carer making referral for my child who is aged between 8 and 11

Please be aware that we are currently experiencing a high demand for our counselling service resulting in extended wait-times.

PRIVACY STATEMENT

Counselling is a private and confidential service. The personal and health information is being collected by Council for the purposes of counselling. This information will be stored in Council’s Customer Database and used to identify the client when communicating with Council and for Council to deliver services and information to the client. We will ensure that the personal information is not disclosed to other individuals, institutions, and authorities outside Council except if required or authorised by law or clear informed consent is given.

The personal information will be handled in accordance with the Privacy and Data Protection Act 2014 (Vic). For further information on how the personal and health information will be handled please refer to Council’s Privacy Policy.

In order for us to provide this child with the most suitable support, please fill all the required sections in this form

Are you or your child a resident, studying, working, or recreating in Wyndham?

Yes

Wyndham Children Counselling Services prioritises children and their families who live, work, study or recreate in Wyndham. This means that your child may not be eligible to access our service. However, you are more than welcome to give us a call on 87341355 to have a chat with one of our children’s counsellors, send an email to middleyearscounselling@wyndham.vic.gov.au or visit us at any of the locations listed below to get more information about our services:

Youth Services @ Hoppers Crossing - 86 Derrimut Road, Hoppers Crossing

Youth Services @ Point Cook - 1-21 Cheetham Street, Point Cook

Youth Services @ Tarneit - 150 Sunset Views Boulevard, Tarneit

Youth Services @ Manor Lakes - 86 Manor Lakes Boulevard, Manor Lakes

Please tick if any of the below applies to your child.

My child is not aware of the referral or not volunteering to receive counselling.

My child needs specialist support for a current or recent sexual assault.

My child needs specialist support due to a current or recent Family Violence.

My child is a victim of a recent or an ongoing crime.

My child needs specialist support for their developmental condition (e.g., ADHD, Autism, Intellectual Disability).

My child is at an immediate risk of suicide, and I am concerned for their safety.

None of the above

Please be aware that we require children to be aware and to volunteer to receive counselling. Please provide more information why the child is not aware of or not volunteering to receive counselling.

BASED ON WHAT YOU'VE TOLD US, OUR SERVICE MAY NOT BE THE BEST FIT FOR YOUR CHILD BECAUSE WE DO NOT SPECIALISE IN SUPPORTING VICTIMS OF SEXUAL ASSAULT. WE SUGGEST SEEKING ASSISTANCE FROM A MORE APPROPRIATE SERVICE. HOWEVER, YOU CAN STILL SUBMIT THIS FORM. IF YOU HAVE ANY QUESTIONS OR WANT TO DISCUSS THIS FURTHER, PLEASE REACH OUT TO OUR COUNSELLING TEAM AT 8734 1355. YOU CAN CONTACT THE SERVICE BELOW TO ACCESS A MORE SPECILASED SERVICE:

Recent Sexual Assault: Please contact West Casa on 1800 806 292 or www.westcasa.org.au or Gatehouse on 9345 6391 or www.rch.org.au/gatehouse/contact/contact_us/ to make a referral into counselling services')

BASED ON WHAT YOU'VE TOLD US, OUR SERVICE MAY NOT BE THE BEST FIT FOR YOUR CHILD BECAUSE WE DO NOT SPECIALISE IN FAMILY VIOLENCE. WE SUGGEST SEEKING ASSISTANCE FROM A MORE APPROPRIATE SERVICE. HOWEVER, YOU CAN STILL SUBMIT THIS FORM IF YOU BELIEVE YOUR CHILD MAY BENEFIT FROM OUR SERVICE. IF YOU HAVE ANY QUESTIONS OR WANT TO DISCUSS THIS FURTHER, PLEASE REACH OUT TO OUR COUNSELLING TEAM AT 8734 1355. YOU CAN CONTACT THE SERVICE BELOW TO ACCESS A MORE SPECILASED SERVICE:

Contact The Orange Door Western Melbourne on 1800 271 045 or in person at 15-17 Watton Street, Werribee 3030. For further information visit their website https://www.orangedoor.vic.gov.au/

BASED ON WHAT YOU'VE TOLD US, OUR SERVICE MAY NOT BE THE BEST FIT FOR YOUR CHILD BECAUSE WE DO NOT SPECIALISE IN SUPPORTING THE CHILDREN AFFECTED BY CRIME. WE SUGGEST SEEKING ASSISTANCE FROM A MORE APPROPRIATE SERVICE. HOWEVER, YOU CAN STILL SUBMIT THIS FORM IF YOU BELIEVE YOUR CHILD MAY BENEFIT FROM OUR SERVICE. IF YOU HAVE ANY QUESTIONS OR WANT TO DISCUSS THIS FURTHER, PLEASE REACH OUT TO OUR COUNSELLING TEAM AT 8734 1355. YOU CAN CONTACT THE SERVICE BELOW TO ACCESS A MORE SPECILASED SERVICE:

Please contact Victims of Crime Helpline (Open 8am-11pm every day):

BASED ON WHAT YOU'VE TOLD US, OUR SERVICE MAY NOT BE THE BEST FIT FOR YOUR CHILD BECAUSE WE DO NOT SPECIALISE IN SUPPORTING CHILDREN WHO HAVE DEVELOPMENTAL ISSUES. WE SUGGEST SEEKING ASSISTANCE FROM A MORE APPROPRIATE SERVICE. HOWEVER, YOU CAN STILL SUBMIT THIS FORM IF YOU BELIEVE YOUR CHILD MAY BENEFIT FROM OUR SERVICE. IF YOU HAVE ANY QUESTIONS OR WANT TO DISCUSS THIS FURTHER, PLEASE REACH OUT TO OUR COUNSELLING TEAM AT 8734 1355. YOU CAN CONTACT THE SERVICE BELOW TO ACCESS A MORE SPECILASED SERVICE:

Please see your GP or refer for NDIS website further information https://www.ndis.gov.au/

PLEASE NOTE THAT WE ARE NOT A CRISIS SERVICE AND CANNOT PROVIDE SPECIALIST PSYCHIATRIC CARE. BASED ON THE INFORMATION YOU HAVE PROVIDED; OUR SERVICE IS NOT SUITABLE FOR YOUR CHILD. IF YOU OR YOUR CHILD IS IN AN EMERGENCY, PLEASE CALL TRIPLE ZERO (000) IMMEDIATELY.

Contact the following services for crisis support:

Lifeline on 13 11 14
Kid help line (for 5–25-year-olds) 1800 55 1800
Royal Childrens Hospital 1800 44 55 11 (free call) to make a referral for specialist services.

Child's Details

Given Name

Family/Surname

Preferred Name

Date of Birth

Age

Gender

Address

Suburb & Postcode

Contact No (if applicable)

Email (if applicable)

Name of their school (if applicable)

Parent/Carer/Legal Guardian details

Full Name

Contact No

Relationship to the child

Is the parent/carer/legal guardian aware of this referral

Yes

Please be aware that we require parent/carer/legal guardian consent for the child to access to counselling support in our service. Feel free to give us a call on 87341355 to have a chat with one our middle years counsellors if you have any questions.

Parent/Carer/Legal Guardian Details (2nd person, if applicable)

Full Name

Contact No

Relationship to the child

Emergency contact

Is the emergency contact the same as the Parent/Carer/Legal Guardian?

Yes

Provide Contact Details

Given Name

Family/Surname

Contact No

Relationship to the child

Is the emergency contact aware of the referral?

Yes

Please inform the parent/carer/legal guardian that in the event we are concerned about the child’s safety or the safety of someone else, this listed emergency contact and relevant legal services will be notified to help keep the child safe.

Tell us briefly why your child needs counselling and what you are hoping to achieve from their engagement with our service:

Does your child or you have any specific needs in order to access counselling? (Disability, interpreter, cultural or religious needs etc.)

Please be advised that we are not a crisis or emergency service, and it may take some time for us to respond to your requests. If you would like to know about the crisis and support services available in Wyndham, visit the Support Services webpage.

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