Counselling referral form

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?

Phone
Txt Message
Email

Counsellor preference

Other Preference

Is the counselling....?

Work related
Personal
Combination work/personal

Do you have any concerns for your safety at work or at home?

Yes
No

Are you at imminent risk of hurting yourself or others?

Yes
No

Do you have concerns about relationship violence?

Yes
No

How soon do you need to see a counsellor?
Please call 0508 664 981 for urgent requests

Urgent (1 - 2 days)
3 - 5 days
Next available

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

Yes
No

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

Counselling referral