Counselling referral form - Your Community Health

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

Emergency contact name

First Last

We will only contact them in an emergency and you want them to be contacted.

Relationship to the emergency contact

Emergency contact's phone number

Does the client have a regular GP (doctor)?

Yes

GP's name

First Last

GP's phone number

Does the client have a case manager?

Yes

Case manager's name

First Last

Case manager's phone number

Are there any other professionals involved in the client's care?

Yes

Name

First Last

Service

Phone number

This field is for validation purposes and should be left unchanged.