Separated Parent and Grief Counselling Referral Form

Separated Parent and Grief Counselling
Lifeline WA provide a Free Counselling Service for Separated Parents, their children and anyone suffering from Grief & Loss.

For further information contact Lifeline WA 08 9261 4498 or visit https://wa.lifeline.org.au/services/counselling-and-support/
Date of Referral*

DayMonthYear
Date
Referred by:

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

YesNo
If NO then do not complete this form. Please contact the office on 9261 4498 or email counselling@lifelinewa.org.au.
Which service are you referring support for (please tick)*

SeparationGrief & LossBoth
Are there any VRO or Conduct Orders in place?*

YesNo
If so, please name the other party*
ABOUT THE CLIENT

Details of Person being referred
Client Name*

First NameLast Name
Date of Birth*

DayMonthYear
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
Emergency Contact Name:

First NameLast Name
Emergency Contact Phone Number
Please enter a valid phone number.
Emergency Contact Relationship
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
Is an interpreter required?
Is the person living with a disability? (if yes, please give details in the 'Other' box)

YesNoOther
Living Arrangements*

Single PersonSole Parent with dependentsCoupleCouple with dependentsGrand Carers - CoupleGrand Carers - SingleExtended Family/KinshipOther (Please State)
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
As part of our referral process one of our counsellors will contact you directly. So that our counsellors can best support you or your friend/family member/client, please provide us with details and information for why you/they are seeking support.

Where possible please include relevant information about the following.
- Why you are wanting counselling support
- Physical health issues or concerns
- Mental health issues or concerns (including any diagnosis or medications)
- 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, conduct/risky 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
- If you/the client is a previous or current serving member of any branch in the Australian Defence Force
- If you/the client is a previous or current first responder (e.g. Emergency Services)
- Any other relevant and helpful details
DETAILS*
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
Please check box to confirm you have attached and sent information that accurately reflects and encompasses client circumstances
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!*

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Separated Parent and Grief Counselling

ABOUT THE CLIENT

ABOUT THE REFERRER