Be.Me. Program Referral Form

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

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

Behaviour Empowerment and
Mindset Evolution (Be.Me.) Program Referral Form

"*" indicates required fields

Name
Gender or Pronouns
Date of Birth
DD slash MM slash YYYY
Address
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

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

Name
Service
Service Provided
Phone
Address
Email
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?