Counselling referral

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

For urgent or emergency requests please call 0508 664 981

Please be assured that the information you give is confidential to Vitae.

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*

Counsellor preference*

Select OneNo preferencesMaleFemaleNAOther

Other Preference

Is the counselling....?*

Work related  Personal  Combination work/personal

Are you at risk of hurting yourself or others?*

Yes  No

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

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

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

Yes  No

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