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*
Which Campus are you enrolled at?*
What is your student ID number?*
Please indicate your status* 
 
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* 
 
 
Please enter the details of your contact option*
Your email address*
Please outline whether issues are study related or personal*
Counsellor preference*
Counsellor preference (If Other)
How soon do you need to see a counsellor?
Please call 0508 664 981 for urgent requests*
 
 
 
Would you be willing to complete a questionnaire on the service provided?* 
 
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 any concerns about relationship violence?* 
 
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