Counselling referral

To make a referral to our counselling service, just fill out the form below.Your request will be processed the following business day.

Please be assured the information collected is confidential.

Referral form

Your Name:*
What organisation do you work for?*
Please provide organisation business group or site you work in*
Please provide business location*
What town or city (suburb) would you prefer to see a counsellor in?*
What is your best contact number(s)?*
Your email address*
Would you be willing to complete a questionnaire on the service provided?*
   
Counsellor preference*
Other Preference
How soon do you need to see a counsellor?
Please call 0508 664 981 for urgent requests*
   
Is the counselling....?*
   
Are you at risk of hurting yourself or others?*
   
Do you have any concerns for your safety at work or at home?*
   
Do you have concerns about relationship violence?*
   
This is a captcha-picture. It is used to prevent mass-access by robots. (see: www.captcha.net)

Please confirm that you are not a script by entering the letters from the image.