I am a professional making referral for a 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

Is the child and/or their family a resident, studying, or recreating in Wyndham?

Yes

Wyndham Children Counselling Services prioritises children and/or their families who live, work, study or recreate in Wyndham. This means that the child may not be eligible to access our service. However, you and the child’s parent/carer/legal guardian are more than welcome to give us a call on 87341355 to have a chat with one of our children 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

Operating Hours: 9am-5pm Monday to Friday (Excluding Public Holidays)

Please tick if any of the below applies to the child

The child or parent/carer/legal guardian is not aware of the referral or not volunteering to receive counselling.

The child requires specialist support for a current or recent sexual assault.

The child requires immediate and specialist support due to a current or recent Family Violence.

The child is a victim of a recent or ongoing crime.

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

The child is at an immediate risk of suicide, and I have current concerns for their safety, or the child requires specialist support for a psychiatric condition.

None of the above

Please note, we need children to know about and volunteer to receive counselling. We also need consent from a parent/carer/legal guardian. Please give more details if the child or their parent/carer/guardian isn't aware of or doesn't want counselling.

BASED ON THE INFORMATION YOU HAVE PROVIDED; OUR SERVICE IS NOT SUITABLE FOR THE CHILD. PLEASE SEE RECOMMENDED SERVICES BELOW. IF YOU WISH TO DISCUSS THIS REFERRAL FURTHER, PLEASE CONTACT THE COUNSELLING TEAM ON 8734 1355

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 THE INFORMATION YOU HAVE PROVIDED; OUR SERVICE IS NOT SUITABLE FOR THE CHILD. PLEASE SEE RECOMMENDED SERVICE BELOW. IF YOU WISH TO DISCUSS FURTHER, PLEASE CONTACT THE COUNSELLING TEAM ON 8734 1355.

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 THE INFORMATION YOU HAVE PROVIDED; OUR SERVICE MAY NOT BE SUITABLE FOR THE CHILD. YOU ARE WELCOME TO COMPLETE THIS FORM BUT PLEASE SEE THE RECOMMENDED SERVICE BELOW FOR MORE TAILORED AND SPECIALISED SUPPORT. IF YOU WISH TO DISCUSS FURTHER, PLEASE CONTACT THE COUNSELLING TEAM ON 8734 1355.

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

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

PLEASE BE AWARE THAT WE ARE NOT AN EMERGENCY OR CRISIS SERVICE OR ABLE TO PROVIDE SPECIALIST PSYCHIATRIC CARE. BASED ON THE INFORMATION YOU HAVE PROVIDED; OUR SERVICE IS NOT SUITABLE FOR THE CHILD. IF THE CHILD IS IN AN EMERGENCY CALL TRIPLE ZERO NOW (000).

The child can access crisis support via the following:

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 Number (if applicable)

Email Address (if applicable)

Name of their school (if applicable)

Parent/Carer/Legal Guardian details

Full name

Contact No

Relationship to the child

Is the parent aware of this referral

Yes

Please be aware that we require parent/legal guardian consent for the child to access to counselling support in our service. Please make sure you obtain their consent before submitting this form. Feel free to give us a call on 87341355 to have a chat with one our middle years counsellors if you need further assistance.

Please provide details about how best to book appointment and any information that would help us establish better communication with yourself and the parent/carer/legal guardian

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

Full Name

Contact No

Relationship to the child

Referrer Details

Given name

Family/Surname

Relationship to the child

Name of your organisation and your title

Work Address

Contact No

Emergency contact

Is the emergency contact the same as the referrer?

Yes

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, we will notify this emergency contact to help keep the child safe.

Provide Contact Details

Given Name

Family/Surname

Contact Number

Relationship to the child

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

Does the child or the parent/carer/legal guardian 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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