Manningham Youth Services Individual Support Intake Form

Manningham Youth Services provide free individual support for young people aged 12–25 who are connected to the Manningham area. To speak to a Youth Engagement Worker about the service, please enter your details below, and someone from the team will be in contact within 3 business days.

Are you seeking support for yourself or someone else?

Seeking Support for Myself

First Name *

Last Name *

Preferred Name

Gender Identity

Preferred Pronoun

Date of Birth *

Country of Birth

Postcode

Do you identify as a First Nations person?

Aboriginal or Torres Strait IslanderAboriginal and Torres Strait IslanderNeitherRather not say

Preferred Language

Do you require an interpreter?

YesNo

Mobile Phone Number *

Email Address *

Preferred Communication *

Relationship to you

If other, advise relationship

Emergency Contact Name

Emergency Contact Mobile Phone

Do your parents know that you are seeking support from Manningham Youth Services?

YesNo

Do you have any accessibility requests?

YesNo

If yes. please provided further details

Reason for Contact

Please advise the main areas of concern that you would like support with. *

What made you decide to seek help now? *

Are there any significant risks that we should be aware of? *

If yes, please advise

If Individual Support was successful, how would your daily life be different?

Do you have anything you would like to share with us so we can be better prepared when we meet?

Do you have a preferred gender of youth worker?

MaleFemaleNo preference

Is there anything else you think we should know? e.g. preferred gender of youth worker, times available etc.

Do you consent to receiving service from Each’s Manningham Youth Services? *

YesNo

Select which time you prefer

AMPM

Consent

Upon receiving this form, we will email you a copy of the Each Welcome Pack. This will include information on your rights and responsibilities, and how you can provide feedback. We will discuss this with you at your earliest convenience.

Seeking Support for Someone Else

Your First Name *

Your Last Name *

Organisation you work for (if professional referral)

Mobile Phone Number *

Email Address *

Preferred Communication *

First Name of Young Person *

Date of Birth of Young Person

Relationship to you

Does the young person know you are seeking support on their behalf?

YesNo

Does the young person have any accessibility requirements?

YesNo

If yes, please provide further details

Can you tell us the main reason you are referring the young person for support *