Wombat's Wish Referral Form
Here, you can make a referral for your own child/young person, or one that you professionally support.
Family Details
Full Name of Parent/Carer
*
First Name
Last Name
Date of Birth
*
-
Day
-
Month
Year
Date
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number (H)
Landline Number
Phone Number (M)
*
Mobile Number
Email
*
example@example.com
What is the best day/times for us to get in touch with you by telephone?
Relationship to Child
Please Select
Mother
Father
Guardian
Other
Children
Name
*
First Name
Last Name
Gender
*
Male
Female
Other
Date of birth
*
-
Day
-
Month
Year
Date
Age
*
Address same as above
Yes
No
Alternative Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Child 2
Yes
No
Child 2 Name
First Name
Last Name
Gender
Male
Female
Other
Date of birth
*
-
Day
-
Month
Year
Date
Age
*
Child 3
Yes
No
Child 3 Name
First Name
Last Name
Gender
Male
Female
Other
Date of birth
-
Day
-
Month
Year
Date
Age
*
Child 4
Yes
No
Name
First Name
Last Name
Gender
Male
Female
Other
Date of birth
-
Day
-
Month
Year
Date
Age
*
Child 5
Yes
No
Child 5 Name
First Name
Last Name
Gender
Male
Female
Other
Date of birth
-
Day
-
Month
Year
Date
Age
*
Deceased Person(s) Details
Name of deceased person
First Name
Last Name
What was the person's cause of death?
Age at Death
Date of Death
*
-
Day
-
Month
Year
Date
Their Relationship to Child
Please Select
Mother
Father
Other
Referral Details
Is this a self referral?
*
Yes
No
Referred by
Job Title/Relationship to Child
Email Address
Address
Phone
*
Are the family aware of this referral?
*
Yes
No
Referral for following Programs
*
Weekend grief program
On Line Lounges
1:1 Counselling
Further Information
What was it that made you decide to contact us at this stage?
Are there any other professional supports involved with the family? If so, please provide details
Are there any issues we should be aware of?
Are there any worries you are aware of about the child/ren?
Is there any further information we should be aware of in regards to the child/ren
Submit
Should be Empty: