Health Coaching Self-Referral Form

Health Coaching Self-Referral Form

Please complete this confidential form to help us understand your needs and determine if our health coaching service could be the right fit for you.
Thank you for taking the time to complete this referral form for Growforte.

The information you share helps us gain a clear understanding of what you’re looking for and ensure that health coaching is a suitable, safe and helpful fit.

All information you provide is treated with care, stored securely.

It will not be shared without your consent, unless required by law or where there is serious concern for your safety or the safety of others.
Personal Details
Full name*
Gender*
Date of birth

DayMonthYear
Date
Phone number*
Email address*
example@example.com
Health Coaching
What brings you to consider health coaching with Growforte today?*
You might like to briefly describe the challenges you’re facing, areas you’d like to work on, and what success would look like for you after coaching.
What type of support are you seeking?*

Package of support (approximately 6–8 sessions)Ongoing Coaching (longer-term support)Group Health Coaching (small group coaching 6-12 participants)Unsure
How would you like sessions to be delivered?*

In-personOnlineA combination of in-person and online
Mental Health and Emotional Wellbeing

The following questions help us understand how you’ve been feeling recently. Please answer as honestly as you can. There are no right or wrong answers.

Over the past two weeks, how often have you experienced the following?*

	0 = Not at all	1 = Several days	2 = More than half the days	3 = Nearly every day
Feeling down, depressed, or hopeless
Feeling anxious, on edge, or panicky
Trouble sleeping
Little interest or pleasure in doing things
Difficulty concentrating

If completing these questions brings things up for you, and you would like to talk to someone for immediate support, please reach out to one of the services available in the link below.
Safety and Wellbeing
Have you had thoughts of self-harm or suicide in the past month?*

YesNo
If you are in immediate danger or feel unable to keep yourself safe

Dial 111 for emergency services

For regional crisis support, please visit the Regional Mental Health Crisis Assessment Teams.

Growforte is not an emergency service does not provide crisis support.
If yes, who have you shared this with?*
Please list: Friends, family, health professional etc.
Are you currently receiving support from other mental health professionals or services?*

YesNo
Please provide details about any mental health supports or services you are receiving.*
Consent and Acknowledgements
I understand that the information I provide will be reviewed by the Lead Health Coach and handled confidentially and stored securely.*

YesNo
I’m aware that referrals are reviewed weekly and that session availability varies.*

YesNo
How did you hear about this service?*

WebsitePREKUREGP or Health ProfessionalWord of mouthWorkshopSocial MediaOther
Would you like to receive updates about services, groups, or workshops?*

YesNo
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