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?
Request Date
Request Type
Age Group
Referrer
![]() Referrer's Name
![]() Referrer's Phone
![]() Referrer's Email
![]() Referral Source
Client Information
First Name
Surname
![]() Date of Birth
![]() School Year
![]() Gender
Residential Address
![]() Street Address
![]() Street Address Line 2
![]() Suburb
![]() State
![]() Post Code
Cultural Identity
![]() Country of Birth
Main language spoken at home
Interpreter needed?
![]() 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
![]() Parent/Carer Name
![]() Phone Number
![]() Are there safety concerns calling this number?
![]() Identified safety concerns to self or others
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