Student Referral - Wellbeing Support

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* 1. I understand that responses to this form are not monitored outside of school hours and that if I need immediate help I will call 000, Kids Helpline 1800 551 800 or Lifeline 13 11 44.

Yes

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* 2. What is your name?

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* 3. What is your email?

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* 4. What year are you in?

7

8

9

10

11

12

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* 5. Who would you like to speak to?

Elise Purnell - School Counsellor / Registered Psychologist

Jessica Liardo - School Psychologist / Registered Psychologist

I don't mind

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* 6. What would you like support with? (tick all that apply)

I am feeling stressed

I am having trouble with friends

I am having trouble managing my schoolwork

I am feeling low / disconnected

I am struggling with my mental health

I am having issues at home

I am struggling to find motivation

I am worried about someone I care about

Other

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* 7. Are you currently seeing anyone to support your mental health (e.g. psychologist / counsellor)?

Yes

No

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* 8. What would you like to get out of meeting with SSO/SC/SP?

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* 9. Would you like to add anything else about what you are experiencing at the moment?