Help Request Form - Menslink
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Help Request Form
"
*
" indicates required fields
Step
1
of
4
25%
Who is completing this
for
m?
*
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 regi
on
*
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 dem
and and
staffing changes,
new referrals to our Counselling service are currently closed
. We hope to re-open referrals later in February 2024, but we d
on’
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 sessi
on
No, I don’t want to organise a counselling sessi
on
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
com
mitment 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 dem
and,
our mentoring program is
on
ly 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
on
ce 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 d
on’
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
for
m.
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
on
ly has a phone number
He
on
ly has an email
I d
on'
t want to provide his contact details
I d
on'
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 so
on
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
on
ly know the phone number
I
on
ly 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 acti
on 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 acti
on
with the referral until we recieve confirmati
on
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 pers
on for
any other reas
on
unless you give us permissi
on.
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 situati
on
It’s helpful for Menslink to get an understanding of what’s going
on
in the young guy’s life situati
on.
Who lives with the young guy
*
Select all that apply.
Mum
Dad
Step Mum / Partner
Step Dad / Partner
Siblings
Grandparent
Partner
Other
No
On
e (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?
*
Depressi
on
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
Com
munity 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, intimidati
on,
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
Depressi
on
Anxiety/Stress
Suicidal thoughts or recent attempt
Drugs and Alcohol
Anger
Bullying
Grief
and
Loss
PTSD
Confidence
and
Self-Esteem
Family Violence
Addicti
on
– video games/porn/gambling
Please provide more informati
on
about the young guy's life, situati
on,
personal circumstances that can help us underst
and
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 situati
on.
Are there any legal or other issues we need to be aware of?
*
Data Collecti
on and
Privacy Policy
*
By submitting this
for
m you give consent to Menslink to use this informati
on
to provide their services, including the off-shore storage of your informati
on.
Please note that if Menslink is served with a Subpoena by a Court of Law to provide informati
on,
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 informati
on
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/Functi
on
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 w
on'
t spam you – we
on
ly send 5-10 emails a year)
*
Yes
No
Email
This field is
for
validati
on
purposes
and
should be left unchanged.
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