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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.
Client Details
Client Name
*
First
Last
Referral Date
*
Date Format: DD slash MM slash YYYY
Client DoB
*
Date Format: MM slash DD slash YYYY
Client Gender
Client Address
*
Street Address
Suburb
State / Territory
Postcode
Client Contact Number 1
*
Client Contact Number 2
Client Email
*
Does the client have any disabilities?
If so, please list.
Is the client a carer for a person with disabilities?
Language spoken at home
Interpreter required?
Yes
Aboriginal Status
Please select the one that best applies
*
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
In the following section please provide details for a parent, guardian, carer, or next of kin.
Name
*
First
Last
Relationship to client
Phone
*
Email
*
Agency Involvement
Are there any other services or agencies involved?
Provide details.
Is counselling a mandatory requirement?
*
Yes
No
Details of Person Making Referral
In the following section please provide your details as the person making the referral.
Referrer's Name
First
Last
Referrer's Email
*
Referrer's Phone
*
Agency
Position
Relationship to Client
Address
*
Street Address
City
State / Territory
Postcode
Has this person (or their legal guardian) agreed to being referred to Yorgum?
*
Yes
No
Reason for Referral
Reason(s) for referral?
*
Suicide & Self Harm
Drug &/or Alcohol
Child Sexual Abuse
Redress
Family Violence
Mental Health
Grief & Loss
Disability Services
Other
Please select all that apply.
Consent
*
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.
Email
This field is for validation purposes and should be left unchanged.
