Youth Counselling Enquiry (Self Referral)

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 (required)

The person is aware of the referral

The person voluntarily wants counselling

The person is over 12 years old

The person has a connection to Wyndham

Reasons for Referral

Why are you making this referral for counselling?

Your Details and Availability

Contact Details

Full Name (required)

Preferred Name

Date of Birth (required)

Age (required)

Gender

Address (required)

Preferred Contact Number Type (required)

Home

Work

Mobile

Contact No (required)

Email Address

Preferred contact method (required)

Phone Call

Text Message

Email

Please provide details about how best to book appointments with you

Emergency Contact Details

Name (required)

Relationship to you (e.g. parent, carer, responsible adult) (required)

Contact No (required)

Is this emergency contact aware of referral? (required)

Yes

No

Please note that if we are concerned about your safety or the safety of someone else, we may need to notify this emergency contact to help keep you or someone else safe. If you do not want that contact to be notified, you should nominate another responsible adult in your life that is available to provide support to you after hours.

I understand and am 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)

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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.