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Contact Us » Make a Referral » Counselling referral form

Counselling referral form

Through our counselling service we work with individuals, couples and families who wish to attend counselling to explore ways of improving their overall life. If you wish to include a significant other or another professional in your care, please discuss this with your counsellor.

The counselling service is available to those who are connected to the city of Darebin. The counselling service is provided free of fees for low and medium income individuals and families. For high income individuals there is a fee that is not claimable against Medicare or health funds.

We are unable to provide services for court mandated, TAC or Work Cover related matters.

We also are not able to provide you with diagnosis, prescribe medication or after-hours services.

Our model of care for counselling includes the following:

  • Phone intake with our service access workers
  • An initial assessment appointment with your counsellor
  • Twelve counselling appointments

If an additional course of care is required, your counsellor will discuss this with you.

A Mental Health Plan is not required, however a referral from your GP with background information is always helpful.

Please complete the form below to make a referral.

Step 1 of 6

16%
Name of person completing this form
I want a referral to counselling services for:
Do you have consent to make this referral?
Please note: If you do not have consent to complete the referral, we apologise as we cannot accept this referral. Please speak to the person and obtain consent prior to completing the referral.
Client's name(Required)
Client's date of birth(Required)
Client's gender(Required)
Client's preferred way to receive communication
Client's residency status
Does the client have any formal supports?
What is their name?
Who does the client live with?
Where does the client live?
Does the client need an interpreter?
Does the client identify as Aboriginal and Torres Strait Islander?
Does the client have a Medicare card?
If yes, please note you be asked for the number when we call you to make an appointment.
Does the client have a Health Care card?
If yes, please note you be asked for the number when we call you to make an appointment.
Does the client have a DVA card?
If yes, please note you be asked for the number when we call you to make an appointment.
What is the client's (or their guardian's) source of income
Emergency contact name
We will only contact them in an emergency and you want them to be contacted.
Preferred method of counselling
Please note, a reliable internet connection, computer and data is needed for a video call.
Preferred office based location
Preferred day of the week for appointments
Preferred time of day for appointments
What are the primary issues or concerns that you want to address with counselling?
Are there any risk issues?
If at immediate risk, please call 000. For after-hours family violence support call Safe Steps on 1800 015 188
Has family violence been reported to the police?
Has an IVO or Safety Notice been issued?
Does the client have a regular GP (doctor)?
GP's name
Does the client have a case manager?
Case manager's name
Are there any other professionals involved in the client's care?
Name
This field is for validation purposes and should be left unchanged.

 

 

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Your Community Health acknowledges the Wurundjeri people of the Kulin Nation are the traditional custodians of the land.

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