Pastoral Care Referral Form

FOR IMMEDIATE/EMERGENCY COUNSELLING SUPPORT please call Counselling Reception on 9634 0873

Student Name(Required)

Staff Name(Required)

Staff Email(Required)

IS ANYONE IN DANGER? (Is the student in danger of hurting themselves? Is the student at risk of hurting someone else? Is someone else going to hurt the student?)(Required)

Yes

No

Please describe the nature of the danger(Required)

Referral Type(Required)

Academic issues/Stress/Motivation

Anxiety

Behavioural issue

Eating concerns/Body image

Family issue

Grief & loss

Interpersonal/Friendship/Relationship

Low mood

Substance use

Trauma

Other

Other Referral Type(Required)

Have you spoken to the student's Dean/Tutor or Parents about this issue before?

Please note: This information will be forwarded to the most appropriate member of the Pastoral Care team for follow up

ROSTERS

Yard Duty
Bus Duty
Briefing Prayers