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Y Counselling Referral Form

Youth Counselling Referral Form

For young people aged 12-25. Referrals to Y WA's confidential youth counselling service - self-referral or professional referral.

Referral details

About the service: Free, voluntary, youth-friendly short-to-medium-term counselling for emotional wellbeing, relationships, coping and day-to-day functioning. The intake team will confirm whether the service is suitable.

Urgent safety: This is not an emergency or crisis service. If there is immediate danger or an urgent risk of harm, call 000 or attend the nearest emergency department.

For a self-referral, leave the referrer fields blank where they do not apply.

Young person's details

Preferred contact method
Contact preference is for
Safe to leave a message via

Parent, carer or support person

Complete where relevant, required by Y WA policy, or agreed by the young person.

Aware of referral
Preferred involvement

Reason for referral and current supports

What would the young person like support with?

Use the young person's own words where possible. Brief information is enough; further assessment occurs after intake.

Main concerns, when they began, any recent changes and how daily life is affected.
Counselling goals or what useful support would look like.
Current supports including mental health.
Only include information that may affect counselling, safety or access.

Brief safety screen

Complete to the best of your knowledge. This supports triage and does not replace a formal risk assessment.

Suicidal thoughts, plan, intent or attempt
Self-harm thoughts, urges or behaviour
Harm to others, aggression or serious impulsivity
Abuse, neglect, family violence, exploitation or unsafe home
Severe mental health deterioration or serious alcohol, drug or eating-related safety concern
For any current/recent concern, note what is known, timeframe, protective factors, safety plan, services contacted and who is following up.
Current safety plan
Immediate follow-up still required

Young person's consent

Consent(Required)
Clear Signature
Verbal consent (if signature can't be obtained)
Parent/carer consent or acknowledgement

Referrer declaration and submission

I confirm that the referral has been discussed with the young person, the information is accurate to the best of my knowledge, and immediate safety concerns have been referred through the appropriate emergency, safeguarding or clinical pathway. Submit the completed form through the approved Y WA referral pathway.

Clear Signature