WelTec Student Counselling Referral Form

Please fill in the following form if you require counselling assistance.

If your need for counselling is urgent and you feel that you are at risk, please call our 24/7 freephone service on 0508 664 981 and request to speak with the counsellor urgently

Name*
Counsellor preference*
Counsellor preference (If Other)
How soon do you need to see a counsellor? Please call 0508 664 981 for urgent requests*	Urgent 1 - 2 days 3 - 5 days
If 'URGENT', are you at risk to yourself or any other person?	Yes No
Which Campus are you enrolled at?*
Please outline whether issues are study related or personal*
What is your student ID number?*
Please indicate the programme that you are enrolled in
Which town/suburb you would prefer counselling to take place?*
Please provide your best contact phone number(s)
Please provide us with your preferred contact option	Email Phone Mobile
Please enter the details of your contact option
Your email address*
Would you be willing to complete a questionnaire on the service provided?*	Yes No