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Refer a student or young person for support

Please complete this form to refer a student or young person for counselling or youth worker support.

We provide prevention and early intervention support for young people aged 10 to 25 years and their families who live, work or study in the City of Bayside.

Please note, we are not a crisis service and should we decide a young person is too complex to offer support we will advocate for a more suitable service.

What is the process?

The information submitted on this form will be sent to the Youth Services Coordinator.

All referrals are discussed at weekly intake meetings and then our staff will make contact either to request further information or to arrange next steps.

If you wish to contact us regarding this form

Email

yscoordinator [at] bayside.vic.gov.au (subject: Refer%20a%20student%20for%20support)  

Phone

(03) 9599 4387




For example a Well-being Coordinator, Youth Worker, Teacher, GP etc.








Referrer's details
For example Student Welfare Coordinator, Family Support Worker etc.
Referrer's details
For example Student Welfare Coordinator, Family Support Worker etc.
Young person's details
















Please select as many as apply.
Young person's details
















Please select as many as apply.
This might include having trouble at home, being bullied, feeling sad, relationship concerns, questioning gender, sexuality or mental health concerns.
Health information
For example anxiety, addictions, ADHD, bi-polar, depression, eating disorders, personality disorders.



























Select as many as apply.
































Select as many as required.



Low risk means

No more than everyday problems or a slight impairment when distressed. No thoughts or action of harm to self of others.

Medium risk means

Moderate difficulty in social, occupational or school functioning and/or fleeting thoughts of harming themselves or harming others but no detailed plans in place.

Warning

Please consider whether this service is appropriate. We work only with young people that require prevention or early intervention support. If this is an emergency or you need further information regarding a young person’s needs please contact:

Ambulance

000

Lifeline

13 11 14 - 24/7 telephone crisis support, as well as online one-one-one crisis support (8pm-Midnight AEST)

Suicide Call Back Service

1300 659 467 - 24/7 professional telephone crisis support for people at risk of suicide, carers and bereaved, as well as online resources and information

Kids Helpline

1800 55 1800 - 24/7 telephone counselling for young people 5–25 years, as well as online and email counselling (check website for hours)

Parent, guardian or emergency contact details






Parent, guardian or emergency contact details