LGBTIQA+ Youth Group sign-up form
headspace Mount Gambier is committed to providing a safe and supportive space for young people part of the LGBTIQA+ community. By being a member of this group, and to help us to cultivate a welcoming and respectful space for everyone that attends, there are some guidelines we all need to agree to follow. By completing this form today, I agree to the following guidelines:
Please tick all that apply:
I agree to be respectful of all other members of the group and of theheadspace staff, and to keep what is discussed during the group confidential.
I agree to follow all instructions that headspace staff give me, andunderstand that if I cannot follow these instructions I may be asked to leave
I consent to providing an emergency contact, whom headspace staff members can contact in the event of an emergency or being asked to leave early
I understand that if I feel overwhelmed or need help then headspace is here to assist me. I know that I can speak to one of the organisers of thegroup in a confidential space, and/or that they can help me to book anappointment to speak with a headspace worker at another time
I consent for my name to be added to the database used by Uniting Communities in order for headspace Mount Gambier to keep a record of thisgroup. I have been told of the privacy and confidentiality guidelines, and I understand that I can withdraw consent at any time
I consent to receiving text messages before the group on the number I have provided, in order to be able to RSVP prior to the group, and I understand I can ask to have the messages stop at any time
I am under 16 and have a legal guardian that can provide verbal or written consent to attend this group
I am aged 16 or over and can provide consent for myself
Young person details
Name
Given name
Last name
Preferred name (if different to given name)
Preferred pronoun(s)
Date of Birth
-
Month
-
Day
Year
Date
Phone Number
Please enter a valid phone number.
Emergency contact
First Name
Last Name
Phone Number
Please enter a valid phone number.
Relationship to young person
Is the young person a current client at headspace?
Yes
No
If yes, please share workers name
Submit
Should be Empty: