ICYMHS Referrals - Avenues Education

Alfred ICYMHS Clinicians can refer students to Avenues Education for an individualised education program

Eastern Health ICYMHS Clinicians can refer students to Avenues Education for participation in:

Individual 1:1 sessions with a teacher
Group sessions when an inpatient at the Box Hill Adolescent Inpatient Unit
Group sessions – Pathways Educational Program (PEP) facilitated in East Ringwood

Eligibility Criteria

Individual students referred to Avenues Education by Alfred or Eastern Health ICYMHS will:

Be under the care of Alfred or Eastern Health ICYMHS and are referred because their learning has been interrupted due to social, emotional, and/or mental health difficulties
Be enrolled in primary or secondary school and retain enrolment in their school of origin

Need signed consent of the parent/carer (and student where appropriate)

"*" indicates required fields

Step 1 of 7 - Authorisation

ICYMHS clinicians require authentication via their email address and an Avenues Education password prior to accessing a referral form.

Your Email *

Password *

Please enter provided password to access the form.

Student Full Name *

First Name Last Name

Date of Birth *

Gender *

Specify Gender *

Year Level *

Address *

Street Address City State / Province / Region ZIP / Postal Code Country

Phone

Aboriginal or Torres Strait Islander

Out of Home Care

Medical Condition

Asthma

Epilepsy

Diabetes

Anaphylaxis

Other

Specify Medical Conditions

Primary Carer 1 - Full Name *

First Name Last Name

Primary Carer 1 - Relationship to student *

Primary Carer 1 - Address *

Street Address City State / Province / Region ZIP / Postal Code Country

Primary Carer 1 - Mobile Phone *

Primary Carer 1 - Email

Primary Carer 2 - Full Name

First Name Last Name

Primary Carer 2 - Relationship to student

Primary Carer 2 - Address

Street Address City State / Province / Region ZIP / Postal Code Country

Primary Carer 2 - Mobile Phone

Primary Carer 2 - Email