Nazareth Years 7-12 Counselling Referral Form

This form is for students in Years 7-12.

ACKNOWLEDGEMENT*
I understand that this is not an emergency service, and by proceeding I acknowledge that although the referral will be responded to within a timely manner, response times may vary. For urgent school related matters, please contact the College on 8406 5300. For crisis support or urgent medical assistance, please call 000 or present at your local hospital.
Who is Referring
Select*
Your details
First name*
Last name*
Year level*
Gender*
Relationship to student*
Contact number*
Email*
Enter Email Confirm Email
MG Teacher
Is the student aware of the referral being made?*
Does the Counsellor need to make contact with you prior to meeting with the student?*
Have parents/caregivers been made aware of this referral?*
Student Details
First name*
Last name*
Year level*
Gender*
MG Teacher
Reason for Referral
What is the reason for your referral? Please describe the current situation and provide any relevant information.
Why would you like to see someone from the Counselling Team? What is happening for you right now? What would you like the Counselling Team to support you with?
Background Information
Please provide any background information that may help us support the student and understand their current situation. I.e. family/living arrangement, social, academic, strengths and/or interests.*
Tell us 3 things about you.*
Additional Support
Are you are aware of any external services, I.e.Psychologist, Psychiatrist, Counsellor, OT and Speech Pathologist, that the student is linked with?*
Please provide additional information if known
Do you have any supports outside of school, I.e. Psychologist, Psychiatrist, Counsellor, OT and Speech Pathologist?*
Please provide additional information if known
As part of our Counselling Team, our Family and Pastoral Care Coordinator provides additional assistance to parents/caregivers through practical support, advocacy and linking families with external services. Would you like to make a referral to our Family and Pastoral Care Coordinator*
Nazareth Family and Pastoral Care Support
Please complete this form to be contacted by our Family and Pastoral Care Coordinator. Click here (opens new tab).
Confidentiality
Maintaining privacy and confidentiality standards are of the utmost importance to our counselling team. For further information on our confidentiality requirements. Click here (opens new tab).
Acknowledgement*

I acknowledge that the information I have provided in this form will be received by the Nazareth Years 7-12 Counselling Team, and may be shared with relevant staff members (Leadership, MG Teachers, House Leaders etc) at the discrecion of the counsellors. While all information provided within referrals and counselling sessions is treated in a respectful and sensitive manner, the sharing of information may at times be necessary in order to meet our duty of care. For further information please click here (opens new tab). Counselling staff will strive to respond to your referral as soon as possible. Please note that referrals may not be received until the following working day and will not be monitored over weekends and school holiday periods. For urgent school related matters, please contact the College on 8406 5300. For crisis support or urgent medical assistance, please call 000 or present at your local hospital.

Nazareth Years 7-12 Counselling Referral Form

Who is Referring

Your details

Student Details

Reason for Referral

Background Information

Additional Support

Nazareth Family and Pastoral Care Support

Confidentiality