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Referral Forms

Online referral form
download referral form
3rd party payment form

Online Referral Form

Please complete the following referral form if you would like to access our counselling services. One of our staff will contact you within two business days with a proposed time and date for a telephone assessment with our Therapeutic Administration Staff. 

Please call us on (08) 6496 0290 if you require further information or if you have not been contacted within two business days. 

Please find a list of providers if you require immediate assistance or crisis care – here.

In the event a staff member has assessed that you or someone else is in danger, the emergency contact provided will be contacted, where one has not been provided we will call either 000 for an ambulance or police to complete a welfare check.
Do you have any children? Please list child/ren’s Names & Dates of Birth

All profits made from Elevate Wellbeing Services and Workshops go straight back to our sister organisation Women’s Health and Wellbeing Services, supporting vulnerable and disadvantaged women and families in your local community. 

visit whws
© 2023 Elevate Wellbeing.
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