Online Referral Form

Please complete this form if you would like to access our counselling services and one of our staff will be in contact with you within 2 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 2 business days. If you require immediate assistance or crisis care please find a list of crisis care providers 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