Do you know a young man at risk of engaging in family, domestic, or sexual violence due to past trauma?

Complete our Be.Me. Program Referral Form below, and we’ll offer trauma-informed counselling, mentoring, and support to guide them toward healing and positive change.

Be.Me. Program Referral Form

"*" indicates required fields

Details of Young Person

Please complete all the sections that you are able to. We recognise that some information will not be available for all families.
Name of young person
Gender or Pronouns
Date of Birth
DD slash MM slash YYYY
Address
Phone
Email
Has the young person agreed to this referral?
If the young person is under 16 years, are the parents/carers aware of referral?
Does the young person identify as culturally or linguistically diverse?
Does the young person identify as Aboriginal or Torres Strait Islander? **
Does the young person identify as Aboriginal or Torres Strait Islander?

Details of Parents / Carers

Parent or Carer Name
Relationship to young person
Gender or Pronouns
Date of Birth
DD slash MM slash YYYY
Address
Phone
Email
Does the young person identify as culturally or linguistically diverse?
Does the parent or carer identify as Aboriginal or Torres Strait Islander? **
Does the young person identify as Aboriginal or Torres Strait Islander?

Details of Referrer

Referring Service
Name of referrer
Role of referrer
Phone
Email
Address
Service provided to young person
Will you or another person from your service have continued involvement with the young person?
Expectations of service delivery

PROFILE OF THE YOUNG PERSON AND FAMILY

Where is the young person living?
Relevant family member details
Historical information
Conflict details
Details of service history involvement
Current orders or upcoming court dates for the young person or family
Current strengths of the young person or family
Any other relevant information
How did you hear about CRS?