Thank you for taking the time to fill out this application form for headspace Liverpool Youth Reference Group. Our Youth Reference Group is for young people aged between 16 – 26 years. The Liverpool Youth Reference Group is a safe and supportive environment for young people to share ideas and voice their opinion on how best we can provide mental health services to our local community.
Basic Information:
Name:
Address:
Best contact number:
Email Address:
Age:
Are you:
Aboriginal Torres Strait Islander
Both Neither
Country of birth:
Do you speak a language other than English at home?
Yes No
If yes, please specify:
Have you or someone you know had a mental health issue in the past?
Yes No
If yes please specify if comfortable sharing:
Which of the following describes your current circumstances?
School student TAFE student University student
Employed part-time Employed full-time Looking for work
Transitioning from study to employment
If you are studying, please write the name of your school/ TAFE/ university and the name of your course in the box below. If you are working, please write the name of your employer in the box.
Additional questions:
What makes you interested in headspace?
What youth mental health issue(s) are you interested in?
What would you do to improve the mental health of young people in Western Sydney if you could be like a super hero?
What is the main reason why you are interested in joining the headspace Youth Advisory Group?
What qualities or skills would you bring to the group?
What are your hobbies and interests?
Where to send this form:
After you have completed this form, please email it to:
Nadine Costantini
Community Engagement Officer
headspace Liverpool
or alternatively give us a call on
8785 3200
What's the next step?
You will receive a thank you email for your interest in joining the youth reference group and then the Community Engagement Officer along with the Chair of the Youth Reference Group will review your application and if successful will arrange a face-to- face interview.
headspace Liverpool Youth Reference Group Application form Page | 2