Counselling Referral Form

Lifeline WA Counselling
Lifeline WA provides a free counselling service available across Western Australia. It is for individuals going through separation and those families who are bereaved by a family member. It can be accessed face to face at our Subiaco office, via Zoom or phone.

If you have any difficulty completing the referral form, please contact the counselling team on 08 9261 4498.
Date of Referral*

DayMonthYear
Date
The client is being referred by:

SelfParentFriendFamilyGuardianPartnerExternal Professional / Organisation / AgencyOther
Is the person aware of this referral and consent to us contacting them:

YesNo
If NO, please do not complete this form and contact the office on 9261 4498 or email counselling@lifelinewa.org.au.
What are you seeking support for?*

SeparationBereavementBoth
How long ago was the separation or bereavement? (Please state whether months or years)*
The separation or bereavement should be within 24 months / 2 years
ABOUT THE CLIENT

Details of Person being referred
Legal Name*

First NameLast Name
Chosen Name
Date of Birth*

DayMonthYear
Age*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
It is safe to:*

leave a messageidentify our serviceneither
Gender*
Pronouns
Are there any VRO or Conduct Orders in place?*

YesNo
If so, please name the other party*
Is there a parenting plan in place?*

YesNo
Does this include the referred client?*

YesNo
Does the other parent consent to this referral?*

YesNo
If yes, please provide their name and contact details
Tell us the ages of your child/children (only if this referral is for a parent/guardian)
If you have no children, this service is not right for you
Young people (dependants aged between 12 and 25 years of age), and primary school aged children
Emergency Contact Name:*

First NameLast Name
Emergency Contact Phone Number*
Please enter a valid phone number.
Emergency Contact Relationship*
Emergency Contact Email
example@example.com
Contact times: Our service operates Monday to Friday, 9am - 5pm. What are the best times for us to contact you? (Referrer and person being referred).
Is the Person being referred of Aboriginal or Torres Strait Islander Australian descent?*
Is the person being referred of a Culturally and Linguistically Diverse (CaLD) background?*
Country of Birth*
Main language spoken at home*
DELETED FIELD - NOT SHOWN ON FORM: Is an interpreter required?

YesNoLanguage
Is an interpreter required?

YesNoLanguage
Is the person living with a disability? (if yes, please give details in the 'Details' box)

YesNoDetails
Living Arrangements*

Single PersonSole Parent with dependentsCoupleCouple with dependentsGroup (Related Adults)Group (Unrelated Adults)Homeless / No household
ABOUT THE REFERRER

If you are referring on someone's behalf, please enter your details below.
Referrer Name*

First NameLast Name
Organisation (if applicable)
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Relationship to the Person being referred, eg: counsellor, case manager, parent.*

General PractitionerPsychologist/TherapistPsychiatristCase ManagerSchool CounsellorParent/GuardianAgencyFamily Member/FriendOther
How did you hear about us?*

headspaceGPWeb SearchSelf / family / friendRefuge / shelterCommunity Service / FSNOther
So that our counsellors can best support you or your friend/family member/client, please answer the following questions as well as you can.
Why you are seeking counselling support*
Physical health issues or concerns (including any diagnosis or medications)
Mental health issues or concerns (including any diagnosis or medications)
Any physical, mental health, disabilities of your dependant children?
Details about any recent hospitalisations
Difficulties in areas such as employment, family or other relationships, education, accommodation, drug and alcohol and legal issues (including family court)
Safety risks or concerns (suicidal ideation or attempts, self-harm, risk to others, risk from others, risk-taking behaviours)
Other services involved (including name & contact details, services/ supports provided, engagement with client)
Issues with violence or aggression. This includes Violence Restraining Orders and criminal convictions
Any previous experiences with counselling & psychological support?
What is the referred person wanting to achieve (goals/outcomes) from counselling support?
For External Professional/Agency Referral, to proceed please attach all relevant documentation. This may include:
- Assessments including any initial or risk assessments, (e.g. HEADSS, CHOICE appt, etc.)
- Engagement summaries
- Referrals from other appropriate services
- Support letter/s
- Client Safety plan & Risk management plan
- Any known criminal convictions
- Discharge summaries
File Upload

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Will your organisation continue engagement/support of this person if they engage with our counselling service? If YES, for how long? If NO, Why? If UNSURE, Why?
Is there anything else you would like to tell us?
I state that the information I have provided above is true and correct!*

Clear
Please note that Lifeline WA's Counselling Services have a 24-hour cancellation policy.
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Lifeline WA Counselling

ABOUT THE CLIENT

ABOUT THE REFERRER