Trauma Counselling Referral Form
RequiredDo you have permission from the client to make this referral and provide their personal information or are you self-referring?

RequiredRequest Date
RequiredRequest Type

RequiredAge Group

Referrer's Name
Referrer's Phone
Referrer's Email
Referral Source

Client Information
RequiredFirst Name
Date of Birth
School Year
Residential Address
Street Address
Street Address Line 2
Post Code
RequiredCultural Identity

Country of Birth
RequiredMain language spoken at home
RequiredInterpreter needed?
Does the client identify with any of the following?

Other Services involved with family
RequiredType of Trauma

RequiredBrief Outline of Issues/Concerns
Other Family Members/Siblings
RequiredConsent to Contact Client
Parent/Carer Name
Phone Number
Are there safety concerns calling this number?
Identified safety concerns to self or others


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