Referral Forms

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