Counselling referral form | Contact us | VitaeContact us

Your Name:

What organisation do you work for?

Please provide organisation business group or site you work in

Do you belong to a professional association? If yes please name

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

What is your preferred method of contact? (email will not be used for urgent referrals and will be accompanied by a notifying text)

Phone
Txt Message
Email

Can Vitae confirm appointments by SMS Text?

Yes
No

Counsellor preference (please refer to the profiles at the top of the page)

Other Preference (ethnicity/ speciality/ other)

Is the counselling....?

Work related
Personal
Combination work/personal

Is your need to talk with a counsellor urgent? (within 1-2 days)

Yes
No

Are you concerned for your safety at work?

Yes
No

Are you concerned about relationship violence or safety at home?

Yes
No

Are you at high risk of hurting yourself or others?

Yes
No

Would you prefer your counselling appointment to be

By Telephone
By web app (Zoom or facetime)
Face to face

Would you be willing to complete a questionnaire on the service provided?

Yes
No

Counselling referral