Counselling Referral - Yorgum Healing Services Aboriginal Corporation

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Client Details

Client Name*

Date of Referral*

Gender*

Date of Birth*

Address*

Contact Number 1*

Contact Number 2

Email*

Does the client have any disabilities?

If so, please list.

Is the client a carer for a person with disabilities?

Yes

Language spoken at home*

Interpreter required?

Yes

Aboriginal Status

Aboriginal

Torres Strait Islander

Aboriginal & Torres Strait Islander

Non-Indigenous with Aboriginal or Torres Strait Islander partner

Non-Indigenous with Aboriginal or Torres Strait Islander children

Parent / Guardian / Carer / Next of Kin Details

Name*

Relationship to client*

Contact Number*

Email*

Agency Involvement

Are there any other services or agencies involved?

Is counselling a mandatory requirement?*

Yes

No

Name of Person Making Referral

Agency referral

Self-referral

Name of person making referral*

Agency

Position

Relationship to person being referred*

Has this person (or their legal guardian) agreed to being referred to Yorgum?*

Yes

No

Mobile*

Phone*

Reason for Referral

Other

It is a requirement of Yorgum that the person being referred in this form has given their express permission for the referee to complete and submit this Counselling Referral Form.*

I have the express permission of the person being referred to do so.