Help Request Form

"*" indicates required fields

Step 1 of 4

25%

Who is completing this form?*

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 10-25 year olds, and our mentoring program is available for 10-16 year olds. We can provide services to males, those who identify as male, and those identify as non-binary. For those outside the age range, click here to see some other services that may be able to help.

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

Mentoring eligiblity – does the young guy live with, or have regular contact with, his Dad or step-Dad?*

Yes

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.

If you have selected to organise a counselling session, you can continue the form below.

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.

Young guy's phone number*

Young guy's email address*

Does the young guy identify as Aboriginal or Torres Strait Islander?*

Yes

Unsure

Prefer not to answer

Is the young guy from Culturally or Linguistically Diverse background?*

Yes

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

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

Parent / Caregiver Details

Parent/caregiver's name*

First Last

Parent/caregiver's phone and email*

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

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?*

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*

Is the Emergency Contact aware of this referral?*

Yes

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?*

Does the young guy have any other significant male role models?*

Yes

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

Phone

This field is for validation purposes and should be left unchanged.