***Menslink Youth 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***
PLEASE NOTE WE SERVICE ONLY CANBERRA  AND ITS SURROUNDS


* 2. Young man's name

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

* 4. Young man's contact number

* 5. Email?

* 6. School attended

* 9. Parent/guardian name (for young men under 18)

* 10. Parent/guardian contact number (if young man is under 18)

* 11. Parent's Email (if young man is under 18)

* 14. Ever been affected by any of the following?

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

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

* 16. Please indicate whether your (grand)son has been affected by any of the following:

* 17. What are the main areas you would like Menslink to help with?

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

* 19. Please give us some general background on your (grand)son including how your believe he could benefit from using our services

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

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

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