headspace Canberra Youth Ambassadors Request Form

hCYA Request Form - For Schools
WORKSHOP REQUEST FORM FOR SCHOOLS AND COMMUNITY ORGANISATIONS
headspace Canberra Youth Ambassadors (hCYA) is a diverse team of young volunteers who are enrolled at university, CIT, and/or participate in a sports club.
Their primary role is to present about headspace and positive mental health to other young people through schools, sporting clubs and other community organisations.

Our workshops utilise the latest interactive audience clicker system, information slides, videos and group activities.

Please allow for a minimum of two weeks to process your request

This form will take around 10 - 15 minutes to complete.

Completing this form will help us make sure we offer you the right kind of presentation for your young people.

If you have any questions or want to talk to us about what we can present to your group, please do not hesitate to contact us on 6201 5343 via email at info@headspacecanberra.org.au
Important notes:
1. If you are a staff member of a secondary school, and concerned about self harm and/or suicide in your school community, please contact the headspace School Support (hSS) team on 0427 748 998 or email schoolsupport@headspace.org.au further information about hSS can be found at headspace.org.au/schoolsupport

2. Due to limited resources, headspace Canberra cannot attend/supply resources to all requests. All requests are subject to availability of our Youth Ambassadors and/or headspace Canberra staff members

3. During university exam and holiday periods, our Youth Ambassadors have limited availability.

4. Currently we can only provide workshops between 10am and 6pm Monday-Friday and require 30-50 participants.

5. We aim to respond to requests as soon as possible. However, please allow for a minimum of two weeks for us to process your request

6. All workshops are delivered to your school/community organisation at no charge. However, we would greatly appreciate any donation that your school/organisation may be able to make to help us continue to work in supporting young people through our workshops.
What is the name of your school/organisation? *

What is the address of your school/organisation? *

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

When would you like the workshop to be held? *
Please provide your preferred date and time. All workshops are offered between 10am and 6pm Monday - Friday
Who is the contact person for this workshop? *
Please include full name and position/title
What is their contact number? *
What is their email address? *
What year level would you like us to present to? (if you are a community organisation, please select 'other' and state age range *

Year 7 Year 8 Year 9 Year 10 Year 11 Year 12
Maximum numbers for workshops are 30 participants. What is the expected number of young people to attend the workshop?
Who from the school/organisation (teacher, school counsellor, youth worker etc.) will be available to support the session delivery? *
At least one staff member of the school/organisation must be present during the session
Has headspace Canberra presented to your school/organisation before? *
If yes, please provide information about the previous session including if it was with the same cohort of young people
The next few questions are focused around the staff at your school/organisation.
Do your staff have access to mental health and wellbeing resources at your school/organisation?

Yes No
Do staff undertake professional development regarding youth mental health and how to assist young people?

Yes No
Do staff know and understand about the headspace Canberra services?

Yes No
Are there members of the staff team who act in a leadership role around mental health and wellbeing?

Yes No
The next few questions are about the Youth Ambassadors program itself: what you want delivered and how
Why would you like headspace Canberra to present to your young people? *

I want young people to gain general information and awareness about mental health and help-seeking I have specific concerns about this group of young people I would like addressed
Please let us know the type of activities which have been/or you plan to undertake with these young people in conjunction with the headspace Youth Ambassadors workshop:
What is your main area of concern for the young people attending the workshop, regarding mental health and wellbeing? *

General mental health Stress (including exam stress) none
What are you hoping/aiming for the outcomes to be for this group of young people by having headspace Canberra present to them?
Does the school or organisation have referral pathways set up for referrals to youth services?
If yes, which services?
The next few questions are about the Talkin' About Your headspace program itself: what you want delivered and how
Does the school/organisation currently provide information to family and friends about youth mental health?
If yes, please specify how. Please note that 'family and friends' is a general term we refer to as the key support people who are involved in the care of young people
Will you be notifying family and friends about headspace Canberra presenting to the young people we are presenting to? *
If yes, how do you plan on doing this? Please note that 'family and friends' is a general term we refer to as the key support people who are involved in the care of young people
Do you plan to provide any follow-up or consultation with family and friends following the headspace Youth Ambassadors workshops at your organisation?
If yes, in what way do you hope to do this? (for example: group or one-on-one consultations, further workshops, surveys etc.).
The next few questions are focused around the staff at your school/organisation.
What kind of room will be used for the workshop? *
Hall, meeting room, classroom
What kind of equipment is available to use for the workshop? (Youth Ambassadors will require an access point for their laptop to enable use of the clicker system) *

desktop computer (Mac) desktop computer (Windows) laptop (Mac) laptop (Windows) data projector projector screen or wall surface smart board or equivalent projector screen or wall surface internet access access to social networking sites (Youtube etc)
Will the Youth Ambassadors have access to the space prior to the workshops? *
If yes, please specify how much time prior they will have
Is there anything else about the setup/space that you feel the Youth Ambassadors need to know?
During the workshops, some of the audience members/staff may be photographed for publicity/promotional purposes (some may appear on our Facebook page/website as well).Would your school/young people/parents/carers be happy for us to do so? *

Yes No
The Youth Ambassadors workshops are delivered to your school/organisation at no charge. However, headspace Canberra reimburses the Youth Ambassadors for their time and expenses (e.g. travel). Any donation or fundraiser that your school/organisation may be able to make to help us continue to work in supporting young people through our workshops would be greatly appreciated.
If you require more information about this, please contact info@headspacecanberra.org.au
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hCYA Request Form - For Schools

Important notes: