Children and Youth Counselling Team Referral Form

Children and Youth Counselling Team Referral Form

Children and Youth Counselling Team Referral Form
GenWest counselling program provides counselling interventions for children, young people and families who have been impacted by family violence in the western metropolitan region.

If a referral does not meet the criteria listed, please contact the counselling team via counselling@genwest.org.au or call 1800 436 937 to arrange a consult.

Eligibility criteria for counselling referrals:*

Rows	Yes
The child/young person is aged between 0 and 17 years.
The main reason for counselling is recovery from the impacts of family violence.
The child or young person does not live with the person using violence.
The child or young person’s primary carer has access to support and can engage in the counselling process.
A current ADULT Family Violence Risk Assessment is attached.
A current CHILD Family Violence Risk Assessment is attached (if completed).

Referring Agency
Agency’s name*
Referrer’s name*
Phone number*
Email address*
example@example.com
Date*

MonthDayYear
Date
Support provided*

Who lives in the house?

Family living description.

Members living with primary carer*

Rows	Name	Age	Relationship to primary carer
1.
2.
3.
4.
5.

Immediate family members not living with primary carer*

Rows	Name	Age	Relationship to primary carer
1.
2.
3.
4.
5.

Person using violence
Name of Person using violence*

First NameLast Name
Relationship to child/young person*
Gender identity*
Date of separation*
Citizen/Permanent ResidentTemporary visaBridging visaOther
If other, please specify:
Another person using violence (if applicable)
Name of Person using violence*

First NameLast Name
Gender identity*
Relationship to child/young person*
Date of separation*
Citizen/Permanent ResidentTemporary visaBridging visaOther
If other, please specify:

Other Agencies

List any other agencies involved with family and provide contact details below:
Agency name*
Worker name*

First NameLast Name
Contact details*
Reason for involvement*

Additional Agencies (if applicable)*

Rows	Agency name	Worker name	Contact details	Reason for involvment
1.
2.
3.
4.
5.

Please attach an up-to-date risk assessment with any other relevant information and forward the referral to GenWest.

Cancelof
Email: counselling@genwest.org.au
Phone: 1800 436 937
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