Be Me Program Self-Referral Form Refer yourself Complete THIs self referral form to get the support you need Who is completing this form?Who is completing this form? Young men and adolescent boys (Age 12-18) Parent Carer/Guardian Your DetailsPlease complete all the sections that you are able to. We recognise that some information will not be available for all families.NameNameGender or PronounsGender or PronounsDate of BirthDate of Birth DD slash MM slash YYYY Phone(Required)Phone Email(Required)Email Other Party Details (Young person, parent or carer)Please complete the details of the other party here.NameNameGender or PronounsGender or PronounsDate of BirthDate of Birth DD slash MM slash YYYY PhonePhone EmailEmail Do you identify as Aboriginal or Torres Strait Islander? (You are welcome to specify cultural connections)Do you identify as Aboriginal or Torres Strait Islander? (You are welcome to specify cultural connections) Yes, Aboriginal Yes, Torres Strait Islander Yes, Aboriginal and Torres Strait Islander No Prefer not to say Do you identify as culturally or linguistically diverse?Do you identify as culturally or linguistically diverse? Who holds parental responsibility/guardianship for the young person?Who holds parental responsibility/guardianship for the young person? Does the young person, or do you, have any disability, mental health condition, or other support needs that we should be aware of to better assist you?Does the young person, or do you, have any disability, mental health condition, or other support needs that we should be aware of to better assist you? Are there any current court orders in place for the young person or family?Are there any current court orders in place for the young person or family? Is the other party aware of this referral?Is the other party aware of this referral?What can we help you with?What can we help you with?