Menslink Referral Form FOR AGENCIES / SCHOOLS etc

***Menslink Mentoring is for males aged 13–18, who are in need of a reliable adult male role model. Menslink Counselling is for males aged 12- 25 who are in need of a supportive counsellor***

MENSLINK SERVICES ONLY CANBERRA AND ITS SURROUNDS

****IN REGARDS TO MENTORING: Please be aware that due to limited spaces we will give priority to young men who have little or no contact with their father.****

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* 1. Service(s) sought

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* 2. Young man's name

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* 3. Current age (please check age requirements above)

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* 4. Young man's contact number

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* 5. Aboriginal or Torres Strait Islander?

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* 6. District currently residing in

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* 7. School attended?

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* 8. Parent/guardian name?

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* 9. Parent/guardian contact number (if client is under 18)?

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* 10. Do we have permission to contact the parent/guardian directly?

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* 11. Others currently residing in household


Mum	Mum menu
Dad	Dad menu
Partner / step-parent	Partner / step-parent menu
Grandparent	Grandparent menu
Brother(s) (inc step, half etc)	Brother(s) (inc step, half etc) menu
Sister(s) (inc step, half etc)	Sister(s) (inc step, half etc) menu
Other	Other menu

Other (please specify)

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* 12. If client isn't living with his biological father, how often does he have contact?

Other (please specify)

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* 13. Has the young person ever been affected by 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 (please provide details below)

Other (please specify)

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* 14. Please indicate if they have ever been affected by:

	Direct victim	Indirect victim / witness	Perpetrator
Physical violence	Physical violence Direct victim	Physical violence Indirect victim / witness	Physical violence Perpetrator
Psychological / emotional abuse (e.g. verbal abuse, intimidation, control)	Psychological / emotional abuse (e.g. verbal abuse, intimidation, control) Direct victim	Psychological / emotional abuse (e.g. verbal abuse, intimidation, control) Indirect victim / witness	Psychological / emotional abuse (e.g. verbal abuse, intimidation, control) Perpetrator
Sexual abuse	Sexual abuse Direct victim	Sexual abuse Indirect victim / witness	Sexual abuse Perpetrator
Psychological / emotional violence (e.g. verbal abuse, intimidation, control)	Psychological / emotional violence (e.g. verbal abuse, intimidation, control) Direct victim	Psychological / emotional violence (e.g. verbal abuse, intimidation, control) Indirect victim / witness	Psychological / emotional violence (e.g. verbal abuse, intimidation, control) Perpetrator

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* 15. Please indicate whether client has been affected by any of the following:

Suicidal ideation

Suicide attempt

Suicide (completed or not) of family member

Other (please specify)

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* 16. In which areas do you hope Menslink's services will impact positively?

	Low priority	Medium priority	High priority
Confidence & self-esteem	Confidence & self-esteem Low priority	Confidence & self-esteem Medium priority	Confidence & self-esteem High priority
General happiness	General happiness Low priority	General happiness Medium priority	General happiness High priority
Peer relationships	Peer relationships Low priority	Peer relationships Medium priority	Peer relationships High priority
Relationships with family members	Relationships with family members Low priority	Relationships with family members Medium priority	Relationships with family members High priority
Taking responsibility for actions	Taking responsibility for actions Low priority	Taking responsibility for actions Medium priority	Taking responsibility for actions High priority
Ability to manage emotions (e.g anger)	Ability to manage emotions (e.g anger) Low priority	Ability to manage emotions (e.g anger) Medium priority	Ability to manage emotions (e.g anger) High priority
Willingness to try new things	Willingness to try new things Low priority	Willingness to try new things Medium priority	Willingness to try new things High priority
General demeanour & attitude	General demeanour & attitude Low priority	General demeanour & attitude Medium priority	General demeanour & attitude High priority
Resilience	Resilience Low priority	Resilience Medium priority	Resilience High priority
Dependence on video games	Dependence on video games Low priority	Dependence on video games Medium priority	Dependence on video games High priority
School engagement	School engagement Low priority	School engagement Medium priority	School engagement High priority
Decision making	Decision making Low priority	Decision making Medium priority	Decision making High priority

Other (please specify)

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* 17. Name of person providing referral

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* 18. Relationship to client

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* 19. Name of agency or school making referral

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* 20. Phone number of referrer

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* 21. Email

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* 22. Please provide the reason for your referral including background on the client

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* 23. Is there anything else, including any legal issues we should be aware of?

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* 24. Is the client currently using any other services?

Other (please specify)

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* 25. By ticking this box I consent to Menslink collecting personal data for anonymous statistical purposes and storing this information offshore.

Yes