Help Request Form

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*

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*

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

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*

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?*

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

No

Help Request Form

Young guy details

Parent / Caregiver Details

Agency Details

Emergency Contact Details

Young guy's life situation

Violent or Abusive Situations

How can Menslink help?