Youth Support Referral

Read before starting

The Middle Years and Youth support program offers support to 8 to 11-year-olds (Middle Years) and 12 to 25-year-olds (Youth). Youth Support Workers provide advice and support on topics such as:

• education and training

• employment

• alcohol and other drug use

• mental health

• legal issues

• family and peer relationships

• service navigation

• other.
  

Eligibility

• Young people aged 8 to 25 who live, work, study or play in the City of Port Phillip.

• Require short or medium-term generalised case management.

Further information

The Youth Support Worker will be in contact within 5 to 7 days to confirm the support process and how they can work with you and the young person to best meet their needs. If you have any questions please contact:

Youth Support

Email: youthsupport@portphillip.vic.gov.au

City of Port Phillip ASSIST

Phone: 9209 6777

Declaration and confirmation

Please confirm who is completing this form: *

I am a young person aged 16 years or older seeking supportI am a parent/carer seeking parenting supportI am a referrer completing this on behalf of a young person

Consent

Consent has been obtained by the parent/guardian to make this referral if the young person is under 16. *

Consent has been obtained for the Youth Support Worker to discuss details of referral with referrer. *

The young person is aware of and consents to this referral if they are 16 years or older. *

Referrer details

Referrer name *

Agency or centre name *

Best phone number to contact you on *

Email *

Young person's details

First name *

Last name *

Date of birth *

Gender identity *Enter "not stated" if you prefer

Street address *

Suburb *

Postcode

Are you currently attending school? *

YesNo

Current school *

Year level *

Country of birth *AustraliaAndorraUnited Arab EmiratesAfghanistanAntigua and BarbudaAnguillaAlbaniaArmeniaNetherlands AntillesAngolaAntarcticaArgentinaAmerican SamoaAustriaArubaAzerbaijanBosnia and HerzegovinaBarbadosBangladeshBelgiumBurkina FasoBulgariaBahrainBurundiBeninBermudaBruneiBoliviaBrazilBahamasBhutanBouvet IslandBotswanaBelarusBelizeCanadaCocos [Keeling] IslandsCongo [DRC]Central African RepublicCongo [Republic]SwitzerlandCôte d'IvoireCook IslandsChileCameroonChinaColombiaCosta RicaCubaCape VerdeChristmas IslandCyprusCzech RepublicGermanyDjiboutiDenmarkDominicaDominican RepublicAlgeriaEcuadorEstoniaEgyptWestern SaharaEritreaSpainEthiopiaFinlandFijiFalkland Islands [Islas Malvinas]MicronesiaFaroe IslandsFranceGabonUnited KingdomGrenadaGeorgiaFrench GuianaGuernseyGhanaGibraltarGreenlandGambiaGuineaGuadeloupeEquatorial GuineaGreeceSouth Georgia and the South Sandwich IslandsGuatemalaGuamGuinea-BissauGuyanaGaza StripHong KongHeard Island and McDonald IslandsHondurasCroatiaHaitiHungaryIndonesiaIrelandIsraelIsle of ManIndiaBritish Indian Ocean TerritoryIraqIranIcelandItalyJerseyJamaicaJordanJapanKenyaKyrgyzstanCambodiaKiribatiComorosSaint Kitts and NevisNorth KoreaSouth KoreaKuwaitCayman IslandsKazakhstanLaosLebanonSaint LuciaLiechtensteinSri LankaLiberiaLesothoLithuaniaLuxembourgLatviaLibyaMoroccoMonacoMoldovaMontenegroMadagascarMarshall IslandsMacedonia [FYROM]MaliMyanmar [Burma]MongoliaMacauNorthern Mariana IslandsMartiniqueMauritaniaMontserratMaltaMauritiusMaldivesMalawiMexicoMalaysiaMozambiqueNamibiaNew CaledoniaNigerNorfolk IslandNigeriaNicaraguaNetherlandsNorwayNepalNauruNiueNew ZealandOmanPanamaPeruFrench PolynesiaPapua New GuineaPhilippinesPakistanPolandSaint Pierre and MiquelonPitcairn IslandsPuerto RicoPalestinian TerritoriesPortugalPalauParaguayQatarRéunionRomaniaSerbiaRussiaRwandaSaudi ArabiaSolomon IslandsSeychellesSudanSwedenSingaporeSaint HelenaSloveniaSvalbard and Jan MayenSlovakiaSierra LeoneSan MarinoSenegalSomaliaSurinameSão Tomé and PríncipeEl SalvadorSyriaSwazilandTurks and Caicos IslandsChadFrench Southern TerritoriesTogoThailandTajikistanTokelauTimor-LesteTurkmenistanTunisiaTongaTurkeyTrinidad and TobagoTuvaluTaiwanTanzaniaUkraineUgandaU.S. Minor Outlying IslandsUnited StatesUruguayUzbekistanVatican CitySaint Vincent and the GrenadinesVenezuelaBritish Virgin IslandsU.S. Virgin IslandsVietnamVanuatuWallis and FutunaSamoaKosovoYemenMayotteSouth AfricaZambiaZimbabwe

Cultural identity *

Preferred language *EnglishArabicChinese (simplified)FrenchGermanGreekHebrewHindiIndonesianItalianJapaneseMalayPolishPortugueseRussianSpanish

Do you need an interpreter? *

YesNo

What language? *

Do you have any additional support or access needs? *

YesNo

What are your support or access needs? *

Indigenous identity *

AboriginalTorres Strait IslanderBothNeitherUnknown

Best phone number to contact you on *

Email

Young person's emergency contact

First name *

Last name

Relationship to young person *

Best phone number to contact you on *

Young person's parent/guardian or carer's information (if under 18)

First name *

Last name *

Email *

Relationship to young person *

Is the parent/primary caregiver aware of this request? *

YesNo

Is an interpreter required? *

YesNo

Please state dialect *

Do you need to add details of another parent or guardian? *

YesNo

First name *

Last name *

Email *

Relationship to young person *

Is the parent/primary caregiver aware of this request? *

YesNo

Is an interpreter required? *

YesNo

Please state dialect *

Support details

Area of support needs *

Education and trainingEmploymentAlcohol and other drug useMental healthLegal issuesFamily and peer relationshipsService navigation

Young person's strengths and interests

What's worked well? What are your/their passions? *

Young person's areas of development

What would you / the young person like to work on? *

Reasons for this request or referral

How can we help?

Data privacy and collection

The personal/health information requested on this form is being collected by the City of Port Phillip (CoPP) and will be handled in accordance with the Privacy and Data Protection Act 2014. This information will be used solely by the council for that primary purpose or directly related purposes. It will be treated in compliance with the CoPP Information Privacy Policy and the Information Privacy Act.

Yes, I give permission for the City of Port Phillip to store and process my data. *

 

Please wait, files are uploading..

Submit

Save and Complete Later

×

Save and Complete Later

Your response has been saved, but not yet submitted.

To come back and continue later, please use this URL:

Copy URL

---

To receive the above link via email as well, enter your email address and click send.

Send

Back to form