Counselling Referral Form

Client Name

First NameLast Name

Address

Street Address

Street Address Line 2

CityCounty

Postal Code

Date of Birth

Date

Email

example@example.com

Mobile Phone

Please enter a valid phone number.Format: (000) 000-0000.

Preferred Method of Contact

Relationship Status

Referral Name (if applicable)

First NameLast Name

Name

First NameLast Name

Phone Number

Format: (000) 000-0000.

Relationship

Are you currently taking prescription medication?

Prescribing Doctor's Name and telephone number

NameTelephone number

If yes, please briefly explain what the medication is:

Have you seen a counsellor, psychologist, psychiatrist or other mental health professional before?

If yes, please briefly explain why and if you found it helpful:

Is this counselling for you?

If it is not for you, please state who it is for.

Which of the following do you need counselling or therapy for?

Please explain briefly what the main issues are for seeking counselling?

What are your main goals to be achieved during counselling?

When would you like the counselling to start?

Other

Please state the best times and days that you would prefer:

Additional comments or concerns

Counselling Fees & Service Information
Inclusive Counselling WA offers professional counselling services for private clients and NDIS participants.

Private Counselling
Private counselling sessions are 50 minutes in duration and are charged at:

$80 per session for Health Care Card, Pension Card or eligible concession card holders.
$120 per session for standard private clients.

NDIS Counselling
Inclusive Counselling WA is a registered NDIS provider. Counselling services can be provided to eligible NDIS participants where counselling is aligned with their plan goals and funded supports.

$156.16 per session
Sessions are 60 minutes in duration

The fee includes the counselling session and the completion of required NDIS-compliant case notes and documentation following the appointment.

NDIS services are billed in accordance with the current NDIS Pricing Arrangements and Price Limits.

Payment Information
Payment is required at the time of service. NDIS participants may be invoiced directly to NDIS, through their plan manager, or via self-management arrangements where applicable.

If you have any questions regarding fees, funding eligibility, or payment options, please contact us prior to your appointment.

*Your signature below indicates that the information you have provided above is truthful and that you are happy to be contacted by admin to process your referral for an appointment

Date

Signature

Counselling Referral Form

Emergency Contact Information

Medical Information

Reason For Counselling