Lilydale Youth Hub

I’m from a community / service organisation

    Introduction

    This form can be used by young people to request help from the Lilydale Youth Hub support team.

    Parents, teachers or other professionals from health services such as mental health, GPs, or social services can also use this form to make a referral on behalf of a young person.

    Please note: to be eligible for this service, you or your client must be aged between 12-25 years of age and either live, work or study in the Yarra Ranges.

    Before you begin:

    It takes 5-10 minutes to fill out this form and you will need to tell us your name, date of birth, contact number, and what you need assistance with.

    Please read our Privacy Statement for information on how your personal information is collected and used by the Lilydale Youth Hub.

    After you complete this form, we will send you an email confirming we have received your request. A team member will then be in touch with you to confirm eligibility and finalise your request.

    Your information is stored on the Lilydale Youth Hub and made available to relevant support staff in line with our privacy policy.

    About

    About the Young Person

    Please contact 000 in an emergency.

    Following contacts also provide crisis support:

    Mental Health Triage – Eastern Mental Health: 1300 321 927

    Lifeline: 13 11 14

    Suicide Line: 1300 651 251

    Who obtained this consent?

    You will need to obtain permission from the young person before proceeding with this referral.

    Parent Details

    Parent Details

    Referrer

    Referrer details

    Supporting-Attachments

    Attachments

    Privacy

    Lilydale Youth Hub Privacy and Confidentiality Statement

    The personal and health information that you have provided will be used by the Lilydale Youth Hub support team to provide you with assistance, advice, and/or support.

    The information will be used by Hub support staff only for that purpose or a directly related purpose.

    It will not otherwise be used or disclosed unless that use or disclosure is permitted or required by law. You may apply for access and/or amendment of the information by contacting the Hub.

    Summary

    Review and Submit

    Thank you for providing your information. Please review everything below to ensure it is correct.

    If you notice any errors, please use the 'Previous' button below to go back and update them. If all information is correct, click the ‘Submit’ button to complete this form.

    Summary

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