School Counselling Referral Form

Student's Details

First NameLast Name

Year Level

Classroom Teacher's Name

Referral Source

External Agency Referral? Please state the organisation.

Referer's Name

First NameLast Name

Phone Number

Area CodePhone Number

E-mail

Best time to contact

Reason for the Referral

Other reason for referral (Please state below)

Please provide further information regarding this referral:

Desired wellbeing outcome:

Relevant History (Is the child on any medications? Does the child have a diagnosis? Is there a history of mental health illness within the family?)

Please upload any paperwork relevant to this referral

Upload a File

Are any other services/organisations involved with this child or family?

Has the child or family had any Department of Children and Families (DCF) involvement?

Parent Consent? Parents will be contacted regarding this referral. Individual Counselling can only take place with parental/guardian consent.

Counsellor Feedback Required?

Is the student aware of the referral?

Privacy and Confidentiality Disclosure

All information shared with the School Counsellor is confidential, meaning the child and families information will not be shared with a third party without prior parental consent. There is however limits to confidentiality.

These limits to confidentiality include:

- School Counsellor's like other Department of Education (DOE) staff, have certain duty of care obligations to all students. The School Counsellor is a mandatory reporter of child abuse and neglect. As specified under Part 5.1 A of the Care and Protection of Children Act 2007.

- If the School Counsellor forms reasonable belief that the student/client is at risk of harm to themselves or others she has a duty of care to report this to a mental health service or to the police.

- If it is disclosed to the School Counsellor that the student/client has engaged in a crime or is going to become involved in such an activity, the School Counsellor will need to contact the Police.

Please note: We will always consult with parents prior to any information being shared with a third party such as an external agency or teacher. We will only share information with a third party if it is in your child's best interest.

School Counsellor's are required to keep a file for each student accessing the School Counselling and Wellbeing Program. These files are kept on a secure database.

If you have any questions in relation to Privacy or Confidentiality, please contact Bakewell Primary School on 08 8931 0487.

I agree to Bakewell Primary Schools Privacy and Confidentiality Disclosure

Bakewell Primary School- School Counselling and Wellbeing Program Referral Form