Young Person Connection Form (Mental Health Support)

Connection to Mental Health Support Service Form

This form is to be completed by the young person seeking support. Answers will be used to assess suitability for this service. Please provide as much information as you would like to support the assessment process. Once completed, your parent/guardian will be contacted within two weeks.
Young Person Details
Full name*

First NameLast Name
Preferred name
Date of birth*

MonthDayYear
Age*
Gender
Pronouns
Address*

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
School / Education setting
Your Contact number*
Please enter a valid phone number.
Your Email
example@example.com
Parent / Guardian Details

Provide details required by policy.
Full name (Parent/Guardian)*

First NameLast Name
Relationship to young person*
Contact number (Parent/Guardian)*
Please enter a valid phone number.
Email (Parent/Guardian)*
example@example.com
Legal guardianship status*
Emergency Contact (Parent or Guardian)

Provide details of an emergency contact.
Name (Emergency Contact)*
Relationship to young person (Emergency Contact)*
Phone number (Emergency Contact)*
Please enter a valid phone number.
How were you connected to us?

Details regarding who and how you are connecting to us.
Source:*

SelfParent/CarerSchoolGPCommunity serviceOther
If you were connected to this service by someone else, please provide their details:
Reason for connection to service

Describe the main concerns and select applicable areas.
What is your primary reason for seeking support?
(tick all that apply)

Stress / overwhelmAnxietyLow moodFriendship or peer conflictSchool disengagementFamily conflictEmotional regulation difficultiesIdentity explorationSocial isolationBehavioural concernsOther
How long have you had these concerns?

Less than 1 month1–3 months3–6 months6+ months
In what area areas of your life does this impact your functioning? (Select all that apply)

SchoolHomePeer relationshipsAttendanceMotivationSleepAppetite
Strengths & Protective Factors

Highlight strengths and supports.
What are some of things you love to do?
What helps when things feel hard?
Supportive relationships (tick all that apply)

Parent/CarerTrusted adultFriendsTeacherCultural/community connectionSporting/community involvement
What are your hobbies/interests?
Do you have cultural strengths and supports?
Do you have spiritual/religious supports?
Mental Health & Medical History

Provide details about mental health and medical history.
Have you had previous therapeutic support?

YesNo
Diagnosed conditions (if known)*
Current medications*
GP details*
Allergies*
Neurodivergence and/or Disability (if applicable)*
Cultural & Identity Information (Voluntary)

This section is voluntary. Your information is kept confidential.
Do you identify as:

AboriginalTorres Strait IslanderBoth Aboriginal & Torres Strait IslanderLGBTQIA+Culturally and linguistically diverse backgroundRefugee/asylum seeker backgroundPrefer not to sayOther
Is English the primary language spoken at home?

YesNo
Declaration of Authorship

By submitting this, I confirm that:
- The information provided in this submission is true and accurate to the best of my knowledge.
- I understand that providing false or misleading information may affect the support I receive.
- I understand that this submission does not automatically guarantee acceptance into the service and that eligibility will be assessed in line with service criteria.
- I acknowledge that the information provided will be reviewed by the Youth Mental Health & Wellbeing Officer for the purpose of determining suitability and providing appropriate support.
By ticking this box, I confirm that I understand that this service isn't suitable for anyone experiencing: thoughts of self-harm, history of self-harm, suicidality, expose to violence, and/or risk to others.*

I confirm
Name*
Signature*

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Parental/Guardian Signature

By submitting this, I confirm that:
- I confirm that I assisted in completing this form and that the responses provided reflect the young person’s own information and intentions.
- The information provided in this submission is true and accurate to the best of my knowledge.
- I understand that this service is not suitable for anyone experiencing thoughts of self-harm, history of self-harm, suicidality, expose to violence, and/or risk to others, and I confirm that my young person is not at risk of these.
- I understand that this submission does not automatically guarantee acceptance into the service, that eligibility will be assessed in line with service criteria and that I will be contacted withi two weeks via phone for a consult.
Name *
Relationship to young person*
Signature

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Connection to Mental Health Support Service Form

Young Person Details

Parent / Guardian Details

Emergency Contact (Parent or Guardian)

How were you connected to us?

Reason for connection to service

Strengths & Protective Factors

Mental Health & Medical History

Cultural & Identity Information (Voluntary)

Declaration of Authorship

Parental/Guardian Signature