Help Request Form - Menslink
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Help Request Form
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Who is completing this form?
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I am a young guy aged between 10 and 25
I am a parent/caregiver of a young guy aged between 10 and 25
I work for an agency and want to refer a young guy aged between 10 and 25
I confirm that I / the young guy lives in Canberra or the surrounding region
*
We are only able to provide support to young guys who are able to attend our Canberra offices.
Yes
Young guy's current age
*
Please note our counselling services are available to young guys aged
10-25 years
, and our mentoring program is available for young guys aged 10-16. For those outside the age range,
click here
to see some other services that may be able to help.
Counselling
Unfortunately, due to demand and staffing changes,
new referrals to our Counselling service are currently closed
. We hope to re-open referrals later in February 2024, but we don’t have a specific date yet. We apologise for the inconvenience.
Counselling
*
Our counselling sessions are informal and there is no diagnosis. We simply provide an opportunity for the young guy to talk through his issues with qualified counsellor, and together they work out ideas on how to make life better.
Learn more here
.
Yes, I want to organise a counselling session
No, I don’t want to organise a counselling session
Please note: Since COVID we have had an increased number of last minute cancellations & ‘no-shows’. Even though we are a ‘no-cost’ service, it costs a lot of money to run our organisation. Late cancellations and no-shows waste our counsellors’ time and prevent services being offered to other young guys who need support.
We are therefore managing late cancellations and no-shows more closely, and this may impact clients’ ability to access our services where we feel there is a lack of commitment to attending. If you want to discuss this policy, please give us a call.
Mentoring
Mentoring eligiblity – does the young guy live with, or have regular contact with, his Dad or step-Dad?
*
Yes
No
Not interested in the Mentoring Program
Unfortunately, due to high demand, our mentoring program is only open to young guys who do not have regular contact with their Dad or step-Dad.
Mentoring
*
Our Mentoring Program pairs up a young guy with a volunteer mentor for a 2 year period. The young guy and mentor catch up about once every two weeks and do lots of fun stuff. Our volunteers are just regular guys with lots of life experience.
Learn more here
.
Yes, I want to apply for the Mentoring Program
No, I don’t want to apply for the Mentoring Program
Young guy details
Here we need the details of the young guy. If you are a parent, caregiver or agency representative, your own details are entered later in the form.
Young guy's date of birth
*
DD slash MM slash YYYY
Young guy's name
*
First
Last
Young guy's address
*
Street Address
Suburb
State/Territory
Young guy's phone and email
*
In the first instance we contact the parent/caregiver/agency about this referral – not the young guy directly.
He has both a phone number and email
He only has a phone number
He only has an email
I don't want to provide his contact details
I don't know his contact details
Young guy's phone number
*
Young guy's email address
*
Does the young guy identify as Aboriginal or Torres Strait Islander?
*
Yes
No
Unsure
Prefer not to answer
Is the young guy from Culturally or Linguistically Diverse background?
*
Yes
No
Unsure
Prefer not to answer
What is the primary language spoken at home?
*
Is the young guy aware of this referral?
*
If not, it is important that you speak to him about the referral as soon as possible. He needs to be an active participant in the process.
Yes
Not yet
Should we contact the young guy directly?
*
Yes
No
Has the young guy engaged in Menslink Services before?
*
Has he had counselling sessions (at our office or at school), or has been inolved in the mentoring program?
Yes
No
Parent / Caregiver Details
Parent/caregiver's name
*
First
Last
Parent/caregiver's phone and email
*
I know both the phone and email
I only know the phone number
I only know the email address
I do not want to / am not able to provide these contact details
Parent/caregiver's phone
*
Parent/caregiver's email
*
Are consent orders in place for parenting/care of the young guy?
*
If you are unsure, you are still able to submit the referral, but please be aware that we need to know the answer before we can take action on the referral.
Yes
No
Unsure
Have all parties to the consent orders agreed to this referral and the young guy's involvement with Menslink?
*
Please be aware that we cannot take any action with the referral until we recieve confirmation that all parties have agreed. If this hasn’t occured yet, please still submit the referral and we will call you to discuss.
Yes
Not yet
Agency Details
Agency contact's name
*
First
Last
Agency contact's phone
*
Agency contact's email
*
Agency Name
*
Who should we call about this referral?
*
Me (Agency contact)
Parent / Caregiver
Young guy directly
Emergency Contact Details
We need this in the extremely unlikely event that something happens when you’re with us. Will will not contact this person for any other reason unless you give us permission.
Emergency Contact Name
*
First
Last
Emergency Contact's phone
*
Emergency Contact's email
*
Relationship to you
*
Parent/Guardian
Grandparent
Sibling
Other
Is the Emergency Contact aware of this referral?
*
Yes
No
Young guy's life situation
It’s helpful for Menslink to get an understanding of what’s going on in the young guy’s life situation.
Who lives with the young guy
*
Select all that apply.
Mum
Dad
Step Mum / Partner
Step Dad / Partner
Siblings
Grandparent
Partner
Other
No One (lives alone)
How many siblings?
*
'Other' details
*
How frequently does the young guy see Dad?
*
Never
Rarely
Occasionally
Regularly
Does the young guy have any other significant male role models?
*
Yes
No
Please describe the relationship and reguarlity of contact.
*
Young guy's school (put N/A if not at school)
*
If the young guy is enrolled in school, how regularly is he currently attending?
Always
Mostly
Sometimes
Never
Not enrolled
Has the young guy been diagnosed with any of the following?
*
Depression
Anxiety
ADHD
Autism/Aspergers
Dyslexia
Personality disorder (e.g. Antisocial, Paranoid, Obsessive-compulsive disorders)
Psychotic Disorder (e.g. Schizophrenia)
Post Traumatic Stress Disorder (PTSD)
Oppositional Defiance Disorder (ODD)
Physical disability
Other
N/A
Please provide further details.
*
Are there any medical issues you feel we should know about?
Is the young guy currently receiving other support services?
*
NDIS Plan
Mental Health Plan
Other Community or Government Support
Private therapy, respite care or support
N/A
Please provide details about these support services.
*
Violent or Abusive Situations
Has the young guy ever been affected by violence or abuse?
Physical Violence
*
Victim
Witness
Directly involved / Offender
N/A
Where did this occur?
*
At Home
At School
Somewhere Else
Psychological / emotional abuse (e.g. verbal abuse, intimidation, control)
*
Victim
Witness
Directly involved / Offender
N/A
Where did this occur?
*
At Home
At School
Somewhere Else
Sexual abuse
*
Victim
Witness
Directly involved / Offender
N/A
Where did this occur?
*
At Home
At School
Somewhere Else
How can Menslink help?
What areas does the young guy need a Menslink Counsellor to provide support in?
*
Relationships
Depression
Anxiety/Stress
Suicidal thoughts or recent attempt
Drugs and Alcohol
Anger
Bullying
Grief and Loss
PTSD
Confidence and Self-Esteem
Family Violence
Addiction – video games/porn/gambling
Please provide more information about the young guy's life, situation, personal circumstances that can help us understand how we can help you the most?
*
It is really helpful for us to get a good amount of detail about the young guy’s life situation.
Are there any legal or other issues we need to be aware of?
*
Data Collection and Privacy Policy
*
By submitting this form you give consent to Menslink to use this information to provide their services, including the off-shore storage of your information. Please note that if Menslink is served with a Subpoena by a Court of Law to provide information, Menslink must do so. Likewise, as a Mandatory Reporter, Menslink is required by law to immediately report child physical and sexual abuse to CYPS. More information can be found in
Menslink’s Privacy Policy
.
I agree
How did you hear about Menslink?
*
Silence Is Deadly Talk, Video or TV Ad
Midweeker
Talk/Function
Social Media
Google/Search
Friends/Family
Other Agency
Other
'Other Agency' / 'Other' details
*
Do you want to receive email updates about Menslink news and events? (we won't spam you – we only send 5-10 emails a year)
*
Yes
No
Name
This field is for validation purposes and should be left unchanged.