Youth Counselling Referral Form (Parent)

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 aged 12-25 years of age

The person has a connection to Wyndham

Reasons for Referral

Why are you making this referral for counselling?

Client Details and Availability

Young person's 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

Parent/Carer Details

Full Name (required)

Preferred Contact Number Type (required)

Home

Work

Mobile

Contact No (required)

Email (required)

Preferred contact method (required)

Phone Call

Text Message

Email

Relationship to the young person (required)

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

Full Name

Preferred Contact Number Type

Home

Work

Mobile

Contact No

Email

Preferred contact method

Phone Call

Text Message

Email

Relationship to the young person

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 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.

I understand and am aware of the above procedure (required)

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.