Boroondara Youth Services referral 1Introduction2Privacy3Support4Referral5Referrer6Attachments7Review You can use this form to: Refer yourself or a young person that you work with for support from Boroondara Youth Services Please note: to be eligible for this service, you or your client must be aged between 10-25 years of age - live, work, study or recreate in the City of Boroondara and require short-medium term support. Before you begin: It takes about 10 minutes to complete this form and you will need to: Tell us your name, date of birth, contact number and type of assistance required - if you're applying for support Obtain consent to release your client's information to Boroondara Youth Services - if you're referring a client Read the City of Boroondara Privacy Statement After you complete this form we will: Send you an email confirming we have received your request What happens to your information? We record your information on the Boroondara Youth Services database and make it available to relevant Youth Services staff in line with our Privacy Policy Youth Services Privacy and Confidentiality statement Your personal and health information is being collected by the City of Boroondara for referral to Boroondara Youth Services to provide you with assistance, advice, and/or support.. The information will be used by Council and its contracted service providers for that primary purpose or a directly related purpose and shall be disclosed to staff in the Boroondara Youth Services team. It will not otherwise be used or disclosed unless that use or disclosure is permitted or required by law. You may apply for access and/or amendment of the information by writing to Council’s Privacy Officer. Consent * Required I consent to the collection/use of my information on this form. What would you like to do today? * Required Request assistance from Boroondara Youth Services Refer a client for support from Boroondara Youth Services Have you obtained consent from the young person/client to make this referral? * Required Yes, written consent has been obtained Yes, verbal consent has been obtained No You will need to obtain permission from the young person/client before proceeding with this referral.You are required to attach a copy of the written consent in the attachments section of this form.Consent was obtained by * Required First name Last name Date of consent * Required DD dash MM dash YYYY Please select the type of support required: * RequiredYou can select more than one of these options. Mental health Education, training or employment Family or relationships General health Housing Alcohol and other drugs Legal support Other Please provide further details on the type of assistance required and young person's support needs. * RequiredPlease include any medical diagnoses, housing, legal and drug and alcohol issues. Name * Required First name Last name Name of young person/client * Required First name Last name Email address * Required Enter Email Confirm Email Mobile phoneHome phoneAddress * Required Street address or PO Box Address line 2 Suburb / City State Post code Country AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Date of birth * RequiredDay12345678910111213141516171819202122232425262728293031Month123456789101112Year20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Age * Required Gender * Required Is a language other than English spoken? Yes No Please list language(s) spoken * Required Will assistance be required from an interpreter? * Required Yes No Please feel free to provide any further information about your support needsWhat's the name of your agency? * Required Your name * Required First name Last name Position title * Required Email * Required Enter email Confirm email Phone number * Required File uploadPlease feel free to attach any further information. You can upload a maximum of 3 files at 4MB each. Allowed file types: jpg, jpeg, png, doc, docx, pdf Drop files here or Select files Accepted file types: jpg, jpeg, png, doc, docx, pdf, Max. file size: 4 MB, Max. files: 3. Maximum file size - 4 mega bytes. I have attached a copy of written consent. * RequiredThis could be a letter from the young person/client or copy of your organisation's registration form which gives authorisation to pass on your client's details to a third party service provider. Yes I have communicated Council's Privacy Policy and the Youth Services Privacy and Confidentiality statement to the young person being referred and they understand how their information will be used. * Required Yes I have read and accept Council's Privacy Policy and the Youth Services Privacy and Confidentiality statement and understand how my information will be used. * Required Yes Please review your information. If you notice errors please use the numbered page navigation or the 'previous' button to make changes. If all information is correct, please click the 'Submit' button to complete this form. {all_fields:exclude[13]}EmailThis field is for validation purposes and should be left unchanged.
