Children Counselling Referral Form - Parents

Privacy Statement

Your personal information is being collected by Wyndham City Council to respond to your enquiry for counselling services. Your information will be used and stored in Council’s Counselling Database and used to identify you when communicating with Council and for the delivery of services and information. For further information on how your personal information is handled, visit Council’s Privacy Policy at https://www.wyndham.vic.gov.au/privacy-policy

I have read and understood the Privacy Statement mentioned above (required)

Criteria Checklists

Is the child aware of the referral? (required)

Yes

No

Is the child aged between 8 –11years? (required)

Yes

No

Does the child or parent live, study, work or recreate in Wyndham? (required)

Yes

No

Date of referral (required)

Client Details

Child's full name (required)

Preferred Name

Date of birth (required)

Age (required)

Gender

Address (required)

Contact No (if applicable)

Email (if applicable)

Parent/Carer Details

Full Name (required)

Contact No (required)

Email (required)

Preferred Contact Method (required)

Phone Call

Text Message

Email

Relationship to the young person (required)

Is the parent aware of this referral (required)

Yes

No

The parent/carer will not be contacted if they are not aware of this referral. In addition, parents are only contacted when young people are under the age of 18 years if required.

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

Full Name

Contact No

Email

Preferred Contact Method

Phone Call

Text Message

Email

Relationship to the young person

Is the parent aware of this referral

Yes

No

The parent/carer will not be contacted if they are not aware of this referral. In addition, parents are only contacted when young people are under the age of 18 years if required.

Emergency contact

Is the emergency contact is the same as the referrer? (required)

Yes

No

Full name

Relationship to child

Preferred Contact Number Type (required)

Home

Work

Mobile

Preferred Contact Number(required)

Is the emergency contact aware of the referral? (required)

Yes

No

Please inform the client that in the event we are concerned about their safety or the safety of someone else, this listed emergency contact will be notified to help keep you safe. If you have concerns about the emergency contact’s ability to keep the client safe or if the client does not want that contact to be notified, they should nominate another responsible adult in their life that is available to provide support to them after hours.

If unsure, please contact us on 8734 1355 and ask to speak to a member of the Counselling Team.

The client understands and is aware of the above procedure (required)

If you aren’t able to provide all of this information, please call Youth Services on 8734 1355 for help to complete this form.

I understand that this referral may not be seen by for up to 48 hours, and that Wyndham City does not offer a crisis support service. (required)

As a result, I understand that if I or someone else is in current danger that I need to contact emergency services immediately. (required)

Immediate help

If require immediate support for your child, please contact any of the following services:

Kidshelpline (for 5-25 year olds) 1800 55 1800
Lifeline (all ages) 13 11 14
If there are any immediate concerns regarding abusive or violent behaviour, you can contact 1800RESPECT on 1800 737 732 or through online chat https://www.1800respect.org.au/
If in immediate danger, please contact 000 for urgent support.

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Acknowledgement of Traditional Custodians

Wyndham City Council recognises Aboriginal and Torres Strait Islander peoples as the first Peoples of Australia. We acknowledge the Bunurong and Wadawurrung Peoples as Traditional Owners of the lands on which Wyndham City operates. The Wadawurrung and Bunurong Peoples have and always will belong to the Werribee Yalook (river), creeks, stars, hills and red clay of this Country. We pay respect to their Ancestors and Elders who always have, and always will, care for Country and community today and for future generations.