Year 13 Support Referral Form
Leaving school brings about many feelings, relief, excitement and stress about what the future holds. This is true for all year groups but the added pressure that your 2020 year 12 group has had due to COVID - 19 has been significant. Due to this we are offering you all ongoing access to support and counselling during 2021.
This form is for you to be able to access extra support for yourself or someone you care about from your year group in a confidential manner. The information you provide on this form will only be provided to Wendy Burgheim ( Centacare Psychologist - Schools Programme) and Mr Andrew Lipszynski ( Centacare -School Counsellor)
IMPORTANT -
** PLEASE NOTE THAT THIS INFORMATION WILL ONLY BE SEEN ON SCHOOL DAYS 8AM - 4PM. **
If you, or someone you care about, is in crisis and you think immediate action is needed you can;
1. Contact and adult you trust and ask for help
2. Call emergency services (triple zero – 000)
3. Call the Mental Health Line 1800 011 511
4. Go to your local doctor or hospital emergency department.
If you or a friend are struggling you can also access extra help and information through the following services:
Phone: Websites:
Mental Health Line - 1800 011 511
www.youthbeyondblue.com
Kids Helpline - 1800 55 1800
www.kidshelpline.com.au
Headspace Orange - 6369 9300
www.eheadspace.org.au
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* Required
Email
*
Your email
Date
*
MM
/
DD
/
YYYY
Who would you like help for
*
Myself
My Friend
Someone in my family
My Child
Other
Name of the person needing support
*
Your answer
The best way to contact them - (please provide a phone number or email address)
*
Your answer
If you are asking for support for someone else are they aware of this?
*
Yes
No
Maybe
If you are asking for support for someone else have you tried to talk to them about your concerns?
Yes
No
Clear selection
If you ticked yes, how did they respond?
They didn't want to talk
1
2
3
4
5
They were happy to talk to me
Clear selection
What would you or your friend like support with?
*
Feeling Anxious
Feeling Depressed
Loneliness
Problems at home
Social Media
Problems with friendships
Relationship difficulties
Careers advice
Body Image
Feeling flat and uninterested in things.
Finding it difficult to control anger
Drugs and Alcohol
Gambling
Other:
Required
If you ticked "other" could you provide some more details
Your answer
How long has this been going on
*
Less than a week
2 weeks
At least a month
6 months or more
I am not sure
Other:
Who would you like to contact you or your friend about this?
*
Wendy Burgheim - Centacare School Psychologist
Andrew Lipczynski - Centacare School Counsellor
I would just like to receive some information about services
I would like to be linked in with outside of school support
I would like help access education options
I would like help accessing work options
I would like to receive a phone to check in to see how I am going
Other:
Required
Is there anything else that you think it is important for us to know?
Your answer
Send me a copy of my responses.
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