• Company Referral Form

    Please provide your details to make a referral.

  • 1. Employer Details

  • Format: (000) 000-0000.
  • Is this person an authorised COS Workforce Wellbeing contact?*

  • 2. Employee Details

  • Format: (000) 000-0000.

  • Safe Contact

  • Preferred method of contact:*

  • 3. The Referral

  • Number of counselling sessions authorised:*

  • Reason for Referral

  • Reason for Referral*

  • 4. Current Concerns

  • Are you aware of any immediate concerns regarding the employee’s safety or wellbeing that COS should know before making contact?

  • Important: COS Workforce Wellbeing is not an emergency or crisis service. If there is an immediate risk to life or safety, the appropriate emergency or statutory service should be contacted rather than relying upon this referral.

  • 5. Counselling Preference

  • If known:

  • 6. Employer Authorisation

  • By submitting this referral, I confirm that:

    The employee knows that the referral is being made.

    • The employee has agreed to COS contacting them.
    • The organisation authorises the stated number of counselling sessions.
    • I understand that counselling content is confidential.
    • I understand that COS will not routinely provide clinical updates, counselling notes or information about what the employee discusses.
    • I understand that any additional sessions beyond the authorised allowance require further approval from the organisation.
    • I understand that the agreed COS cancellation and charging terms apply.
  • By submitting this referral, I confirm that:*
  • Date:*
     - -
    2 digit month, 2 digit day, 4 digit year

  • Once submitted, COS will contact the employee directly to arrange their counselling. From that point, the therapeutic relationship is between COS and the employee. Funded by the employer. Independent for the employee.

  • Should be Empty: