Trauma Counselling Referral Form
Do you have permission from the client to make this referral and provide their personal information or are you self-referring?
Date of Birth
Street Address Line 2
Country of Birth
Main language spoken at home
Does the client identify with any of the following?
Other Services involved with family
Type of Trauma
Brief Outline of Issues/Concerns
Other Family Members/Siblings
Consent to Contact Client
Are there safety concerns calling this number?
Identified safety concerns to self or others