Support Request Form

Support Request Form Instructions: - If you are a young person, please complete Section 1 only and Submit (you can skip Section 2) - If you are a parent/carer or a worker requesting support for a young person, please complete Section 2 only and Submit (you can skip Section 1) Section 1: Your name Your preferred name Pronouns (he/him, she/her, they/them etc) Your age Do you live, work, study, or play in Maroondah? (select one) Yes
No How did you hear about the Youth Support Service? What do you need support with? You can select one or more options Relationships (friends, romantic, family)
Sexuality/gender
Education/employment
Alcohol or other drugs
Housing
Mental health (stress, anxiety, depression, grief/loss, bullying)
Personal safety (violence, abuse, trauma)
Practical life skills (budgeting, nutrition, help with appointments)
Other If 'other', please specify Please list at least 1 goal that you'd like support with Is there any other information we might need to make sure we can get you the support you need? How would you like us to contact you? (select one) Please select Text Phone Call Email Your contact details If you are requesting support of behalf of a young person, please complete Section 2 only and Submit (skip Section 1) Section 2: Your Name Your relationship to young person (select one) Parent/carer/guardian Other family members Teacher Youth Service Provider Other (please specify) Young person's name Young person's age Does the young person live, work, study or play in Maroondah? (select one) Yes
No Please provide a brief outline of the support required for the young person Is the young person aware of the support request being made Yes No Please note that we will contact you before we attempt contact with the young person. How would you like us to contact you? (select one) Text Phone Call Email Your contact details Young person's contact details PRIVACY COLLECTION NOTICE Maroondah City Council is committed to protecting your privacy as prescribed by the Privacy & Data Protection Act 2014 and the Health Records Act 2001. The information you provide on this form is being collected by Maroondah City Council for the strict purpose of conducting Council business. Your information will not be disclosed to any external party without your consent, unless Council is required or authorised to do so by law. Failure to provide the information requested may make you ineligible to receive the service or be part of an event/function that is the subject of this form. Any access to the information, amendments that may be required or any privacy enquiries may be directed to Council's Privacy Officer & Health Records Officer on 9298 4211 or email - privacy@maroondah.vic.gov.au Submit: Our team works Mon-Fri, 8.30am - 5.00pm (excluding public holidays). We will do our best to get in contact with you within 2 business days of receiving your form. If you have any questions or any difficulty completing this form, please contact Youth Services on 9294 5704. Thank you! Submit