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

Criteria Checklists (required)
Are any main presenting concerns for the referral

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'

Recent Family Violence: Please contact Women's Health West on 9689 9588 or www.whwest.org.au to make a referral into counselling services.

Current Alcohol and other drug issues and requiring support through detox or abstinence: Please contact Western Health Drug Health Service on 8345 6682 www.westernhealth.org.au for a referral into counselling services/programs.

Recent experienced crime as a victim: Please contact Victims of Crime on 1800 819 817 or www.victimsofcrime.vic.gov.au/ for counselling services.

Current or past diagnosis of Borderline Personality disorder or Psychosis: Please contact Orygen Youth Health on 1800 888320 or www.oyh.org.au or advise client to visit GP for a Mental Health Care Plan to consult with a private psychologist for counselling services.

Client Details and Availability
Days Available (required)
Methods of counselling you are willing to receive (required)
Which locations you would like to attend your sessions
Young person's details
Parent/Carer details
Preferred Contact Number Type (required)
Preferred Contact Method (required)
Is the parent aware of this referral (required)

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)
Preferred Contact Number Type
Preferred Contact Method
Referrer Details
Preferred Contact Number Type (required)
Preferred Contact Method (required)
Emergency contact
Is the emergency contact the same as the referrer? (required)
Preferred Contact Number Type (required)
Is the emergency contact aware of the referral? (required)

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

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