TEST - Your Community Health

Counselling Referral Form 2023

Welcome to Your Community Health (YourCH) Counselling program! Prior to completing this form, we would like to share some essential information about our Counselling program with you. By completing this form, you consent to us contacting you or your client to complete the referral and book an appointment.

Step 1 of 8 - Please read, tick to confirm that you have read this form and agree to proceed with our service.

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Information on YourCH Counselling

General Counselling info(Required)

Attendance is voluntary and I can cease using the Counselling service at any point without it impacting on my access to other YourCH services.

My first appointment involves an assessment that asks a broad range of questions and assists the clinician to understand my history, issues and to make referrals to other services as needed. If I am uncomfortable with any of the questions or find them intrusive, I am aware I can raise this with the clinician.

I can bring a significant other, loved one or therapy animal to a session and will notify my clinician prior to my appointment if this is happening.

If I require an interpreter, YourCH will endeavour to have an accredited interpreter present for all scheduled appointments and this will be provided at no cost to me.

The Counselling service is free of charge for low and medium income earners, for others there may be a fee.

I may be recommended or suggested referrals to other services within or external to YourCH and some of these services may incur a cost. This will be discussed with me prior to a referral being made.

I can read through the New Client Welcome Pack online https://www.yourch.org.au/getinvolved/new-client-welcome-packs , which includes information on my privacy, rights and responsibilities, and opportunities to mae suggestions, give feedback, or make a complaint.

For all clients accessing services at YourCH, an emergency contact is required in case we have concerns for your safety or wellbeing, or must contact Emergency Services on your behalf.

Emails between yourself and your clinician are not encrypted (encryption allows information to be hidden so that it cannot be read without special knowledge, such as a password).

Confidentiality(Required)

YourCH receives government funding and therefore, demographic information and other de-identified data is provided securely to these bodies where necessary. No personal and confidential information is shared with funding bodies.

My contact with YourCH and what I share with my Counsellor is kept private and confidential .

My Counsellor will not speak to another professional or person in my life without my consent.

If I wish to include others in my care or my Counsellor suggests this may be useful, my Counsellor will ask me for consent and contact details.

As a YourCH client, a health record will be created where my Counsellor will keep notes and documentation. It is kept in a secure electronic database that only YourCH relevant employees have access to

As part of professional practice, my Counsellor may discuss their work with me in individual and/or group supervision.

Limits of confidentiality - all YourCH employees are legally and ethically obliged to keep my personal and sensitive information private and secure. All matters discussed in my sessions are confidential except under the following circumstances:(Required)

Where my safety and wellbeing are at immediate risk.

Where someone’s else safety and wellbeing are at immediate risk.

I state that I am going to commit a crime.

I report that I have committed a major crime.

Where the overall wellbeing of a child or children is at long term risk.

My Counsellor and/or YourCH health record are subpoenaed by a court.

If I have been referred via the courts or justice system, my attendance will need to be disclosed with the designated justice professional.

Attendance(Required)

Counselling at YourCH Service has an initial assessment appointment followed by a 12-session course of care model.

The frequency of sessions will vary depending on the nature of my concerns.

A review will occur approximately after six sessions; this is an opportunity to review progress towards my goals and to seek my feedback on the service so far.

After my course of care, I will need to have a break of three months prior to being referred again.

I will attend all sessions punctually and give at least 24 hours advance notice to cancel or reschedule.

I will notify YourCH if I am going to be more than 15 minutes late for my appointment. If I am late, my session may be shortened on the day due to other appointments.

If I miss two or more consecutive appointments and YourCH hasn’t had contact from me for three weeks, YourCH will assume I no longer wish to have Counselling. However, this does not prevent me from re-accessing the service in the future.

I will advise my Counsellor if I want to stop Counselling, prefer to see a different Counsellor or the service is not meeting my needs.

In the interests of safety and the Counselling process, YourCH requests that I am not affected by substances and if so, they will cancel or reschedule my appointment. My Counsellor may reschedule my appointment and address any safety needs (i.e. assisting to arrange alternative transport) if I do attend my appointment substance affected.

Contacting your clinician(Required)

Counselling is not a crisis or emergency service. If you require Emergency Services, YourCH recommend you ring 000. If you are having a mental health or psychiatric crisis, please contact your local triage number (your Counsellor will provide you with the local service if required).

The Counselling service only operates during business hours Monday to Friday, 9am–4:30pm.

Many Counsellors work part-time and, due to the demand for the service, are not always available to take calls. They will endeavour to return calls within two business days. If the matter is urgent (e.g., needing to cancel appointment) please call our main number (03 8470 1111) and advise the receptionist or leave a clear message on the Counsellors voicemail.

As part of your assessment or Counselling, it could be useful to develop a Coping/Resource Support Plan where you can contact appropriate supports and services between counselling appointments, as your Counsellor may not always be available to talk to you. If you need assistance outside of business hours, you can call a relevant number listed above.

Counselling is a process of identifying and clarifying issues/goals, exploring options, developing strategies and ways to manage things differently and increasing self-awareness. It is a collaboration between you (with your knowledge, experience and strengths) and your clinician who brings their own style, therapy models and the techniques they are trained in. A care plan developed between yourself and your clinician is often useful to share with other health professionals involved in your life.(Required)

I, the client, understand the Counselling Service at YourCH and agree to receive the service as outlined .

I, the healthcare professional, have explained this to my client and they have verbally consented to me completing this referral on their behalf.

Referral information

Name of person completing this form(Required)

First Last

I want a referral to counselling services for:(Required)

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?(Required)

Yes

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(Required)

Phone

Post - this may take some time and cause delays

Client's residency status(Required)

Citizen

Resident

On a Visa

Refugee

Asylum Seeker

Other

If the client is a refugee or asylum seeker, when did they 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

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

Does the client have a Medicare card?

Yes

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?

Yes

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?

Yes

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

No income

Pension/Benefit

Part-time work

Full-time work

Other

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

Preferred method of counselling

No preference

Phone

In person

Video call

Please note, a reliable internet connection, computer and data is needed for a video call.

Preferred office based location

East Reservoir

Northcote

Preston (PANCH)

Preferred day of the week for appointments

No preference

Monday

Tuesday

Wednesday

Thursday

Friday

Preferred time of day for appointments

No preference

Morning

Afternoon

What are the primary issues or concerns that you/ your client want to address with Counselling?

Emotional wellbeing/Mood

Relationships

Loss/Grief

Life stage

Health

Trauma/Abuse

Family violence (victim-survivors only)

Other

If other, please specify.

What are your hopes for Counselling?

Are there any risk issues?

Chronic health issues

Addiction

Self harm/Suicide

Family violence

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?

Yes

Has an IVO or Safety Notice been issued?

Yes

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

Pre-session questions

To assist in best matching you with a Counsellor, please complete the following questions.

How often does the issue(s) present in your life and what triggers or sets off the issue(s)?

How does the issue/s interfere with your daily life and how would you describe the main problems it is causing you?

How have you tried to 'fix', 'seek help' or 'address the problems' in the past, and what was helpful?

Who else in your life thinks this is an important issue or a priority for you right now?

What helped you to decide now was the 'right' time to seek Counselling?

What do you see as the focus and priority areas for Counselling? If these were addressed, how would you know if Counselling worked for you?

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

Counselling Referral Form 2023

Information on YourCH Counselling

Referral information

Pre-session questions

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