1800 469 371
176 Wittenoom Street, East Perth WA 6004
Counselling Referral Form
Once completed, the contents of this document are PRIVATE and CONFIDENTIAL. Information will not be released or reproduced without the permission of the author or Yorgum.
Date Format: DD slash MM slash YYYY
Date Format: MM slash DD slash YYYY
State / Territory
Client Contact Number 1
Client Contact Number 2
Does the client have any disabilities?
If so, please list.
Is the client a carer for a person with disabilities?
Language spoken at home
Please select the one that best applies
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
In the following section please provide details for a parent, guardian, carer, or next of kin.
Relationship to client
Are there any other services or agencies involved?
Is counselling a mandatory requirement?
Details of Person Making Referral
In the following section please provide your details as the person making the referral.
Relationship to Client
State / Territory
Has this person (or their legal guardian) agreed to being referred to Yorgum?
Reason for Referral
Reason(s) for referral?
Suicide & Self Harm
Drug &/or Alcohol
Child Sexual Abuse
Grief & Loss
Please select all that apply.
I have the express permission of the person being referred to do so.
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.
The referrer should receive a confirmation of submission via the email address provided. Please contact Yorgum Healing Services if you do not receive one within 24 hours of submission.
This field is for validation purposes and should be left unchanged.
Save and Continue Later