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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Email *
Date *
MM
/
DD
/
YYYY
Who would you like help for *
Name of the person needing support *
The best way to contact them - (please provide a phone number or email address) *
If you are asking for support for someone else are they aware of this? *
If you are asking for support for someone else have you tried to talk to them about your concerns?
Clear selection
If you ticked yes, how did they respond?
They didn't want to talk
They were happy to talk to me
Clear selection
What would you or your friend like support with? *
Required
If you ticked "other" could you provide some more details
How long has this been going on *
Who would you like to contact you or your friend about this? *
Required
Is there anything else that you think it is important for us to know?
Submit
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