CBWWYN Referral form

If you are a young person aged 12 to 24 and are looking for support, please complete the referral form below. You can also have a parent, guardian, teacher or support person complete the form on your behalf.

Youth support may include assistance with education, employment, training, housing, mental health and wellbeing, financial difficulties, family or relationship challenges, social connection, and accessing other community services.

Once your referral is received, Council's Youth Development Officer will review your needs and identify the most appropriate support options. This may include providing information, connecting you with relevant services, advocating on your behalf, or referring you to a specialist youth service. You will then receive an email with details of the recommended organisation and worker, including their contact information and next steps.

* Please note if the referral is created on behalf of a young person, you will require their consent before proceeding.

Date

Is this a self-referral? *

YesNo (If no, please ask the Young person for their consent)

Has the young person provided consent? *

YesNoN/A

Young person details

Full name *

Name of school

Suburb *

Date of birth *

Gender *

Email *

Contact number *

Reason for referral *

Which of the following concerns have been identified? Tick all applicable concerns *

Are other services involved? If yes, please provide more details

Referrer details

Referrer name (if applicable)

How do you know the young person?

Which school are you from?

Email

In submitting this form, you consent to Council:

1. collecting your personal information as contained in the form; and

2. using the information for the purposes outlined in the formand for any other Council function.

Providing your information is voluntary. Should you choose not to provide the information, Council is unable to process your application/request. You may access any of your personal information that Council holds upon request.