Counselling

Name of person completing this form

First Last

I want a referral to counselling services for:

Myself

My child aged 10 to 18 (I am their parent or guardian)

My client (I am a health or support professional)

Other

Do you have consent to make this referral?

Yes

No

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.

Referrer's Phone Number(Required)

Referrer's Email(Required)

For professionals who will provide ongoing support:

Email Correspondence please use my email address

Clients does not have an email

Client's name(Required)

First Last

Client's date of birth(Required)

Client's gender(Required)

Female

Male

Transgender

Non-binary

Other

Prefer not to say

If other, please specify

Client's address(Required)

Suburb(Required)

Postcode(Required)

Client's phone(Required)

Client's email(Required)

Client's preferred way to receive communication

Phone

Email

Post - this may take some time and cause delays

Client's residency status

Citizen

Resident

On a visa

Refugee

Asylum seeker

Other

If you are a refugee or asylum seeker, when did you arrive in Australia?

Does the client have any formal supports?

No - not applicable

Carer

Guardian

Administrator

Power of Attorney

NDIS or My Aged Care Case Manager

What is their name?

First Last

What is their phone number?

Who does the client live with?

Alone

Friends

Family

Other

Where does the client live?

Own home

Rental (private)

Public housing

Temporary accommodation

Homeless

Other

Country of birth

Preferred language

Does the client need an interpreter?

Yes

No

Does the client identify as Aboriginal and Torres Strait Islander?

Aboriginal

Torres Strait Islander

Aboriginal and Torres Strait Islander

No - Neither Aboriginal or Torres Strait Islander

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

No

GP's name

First Last

GP's phone number

Does the client have a case manager?

Yes

No

Case manager's name

First Last

Case manager's phone number

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

Yes

No

Name

First Last

Service

Phone number

Email

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

Your Community Health

Counselling can be a helpful way to improve your social and emotional wellbeing.

Reconnexion

Counselling Referral Form

Search Your Community Health