Wellbeing and Support Referral Form
Sometimes everyone needs some extra support. This form is for you to be able to access extra support for yourself or someone you care about 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)
** 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:
Mental Health Line - 1800 011 511
Kids Helpline - 1800 55 1800
Headspace Orange - 6369 9300
School TV link on
Who would you like help for
Someone in my family
Name and year group 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?
If you ticked yes, how did they respond?
They didn't want to talk
They were happy to talk to me
What would you or your friend like support with?
Problems at home
Problems with friendships
Feeling flat and uninterested in things.
Finding it difficult to control anger
If you ticked "other" could you provide some more details
How long has this been going on
Less than a week
At least a month
6 months or more
I am not sure
Who would you like to contact you or your friend about this?
Wendy Burgheim - Centacare School Psychologist
My Year Coordinator
Andrew Lipczynski - Centacare School Counsellor
I would just like to receive some information about services
Is there anything else that you think it is important for us to know?
Send me a copy of my responses.
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