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:

Other
Is the person aware of this referral and consent to us contacting them:
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?
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.Format: 0000 000 000.
Email
example@example.com
It is safe to:
Gender
Do you identify as LGBTQIA+ ?
Pronouns
Are there any VRO or Conduct Orders in place?
If so, please name the other party
Is there a parenting plan in place?
Does this include the referred client?
Does the other parent consent to this referral?
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.Format: 0000 000 000.
Emergency Contact Relationship
Emergency Contact Email
example@example.com
Contact times: Our service operates Monday to Friday between 8:30am - 4:30pm. 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?

Language
Is an interpreter required?

Language - Please click here to tell us
Is the person living with a disability? (if yes, please give details in the 'Details' box)

Details
Living Arrangements
Has the referred person made a suicide attempt in the past?
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.Format: 0000 000 000.
Email
example@example.com
Relationship to the Person being referred, eg: counsellor, case manager, parent.

Other
How did you hear about us?

Other
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

Cancelof
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!
Please note that Lifeline WA's Counselling Services have a 24-hour cancellation policy.
For information about Jotform’s Privacy and Security, please see the following links.

Jotform Privacy Jotform Security
Should be Empty:

Lifeline WA Counselling

ABOUT THE CLIENT

ABOUT THE REFERRER