WRF

Wellbeing Referral Form 2026

Use this form to refer a student to the wellbeing department. Please remember students must have given consent for a referral. Students/staff will be allocated to a Wellbeing Case Manager post the Allocation Meeting on Tuesday mornings. Thank you, The Wellbeing Team

Role of referring Person(Required)

Name of referring Person(Required)

First Last

Name of student being referred(Required)

First Last

Student SSSC Email(Required)

Enter Email Confirm Email

Has the student given consent for this referral?(Required)

Yes

Are parents/carers aware of this referral?(Required)

Yes – Wellbeing consent form must be completed.

No – Wellbeing consent form must be completed.

Main reason for referral(Required)

FOR REFERRALS BY SCHOOL STAFF:

Is there anything that has already been done to support the student? For example: special provisions, supportive conversation to establish student needs, learning adjustment in the classroom, support meeting with Manager etc.

FOR REFERRALS BY PARENTS / GUARDIANS:

Is there anything that has already been done to support the student? For example: external supports in place (GP, mental health care plan, psychologist / psychiatrist referral), supportive conversation to establish student needs, contact with school staff (classroom teacher, Careers Advisor) etc.

Any other comments?

Wellbeing Referral Form 2026

Swinburne Senior Secondary College

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