Counselling Referral Form

Details of individual being referred

Name:	Click or tap here to enter text.
Address:	Click or tap here to enter text.
Suburb:	Click or tap here to enter text.
Date of birth:	Click or tap here to enter text.
Phone number:	Click or tap here to enter text.
Mobile number:	Click or tap here to enter text.
Email address:	Click or tap here to enter text.
NDIS number (if any)	Click or tap here to enter text.
Plan is	☐ Agency managed ☐ Self managed ☐ Plan managed If plan managed, please provide name and email address of plan manager: Click or tap here to enter text.

Is there a guardianship order in place? ☐ Yes ☐ No
If yes, is the guardian aware of this referral? ☐ Yes ☐ No
Please provide details of guardian: Click or tap here to enter text.

Details of next of kin / emergency contact

Name:	Click or tap here to enter text.
Address:	Click or tap here to enter text.
Suburb:	Click or tap here to enter text.
Phone number:	Click or tap here to enter text.
Mobile number:	Click or tap here to enter text.
Email address:	Click or tap here to enter text.

Details of person referring

Name:	Click or tap here to enter text.
Organisation:	Click or tap here to enter text.
Phone number:	Click or tap here to enter text.
Mobile number:	Click or tap here to enter text.
Email address:	Click or tap here to enter text.

History

Does the person have any of the following?

Current mental health issues	☐
Suicidal ideation	☐
Behaviours of concerns	☐

If so, please provide details / management strategies in place:

Click or tap here to enter text.

Disability:

Intellectual	☐
Autism	☐
Other, please specify	☐ Click or tap here to enter text.

Reason for referral and issues to be addressed

Please provide as much information as you can about the reason for referral and what issues you would like addressed.

Click or tap here to enter text.

Consent Form

I, ________________________________________________ (client’s name) consent to attend an initial session with Yvonne Kesselring.

Signature of person being referred _______________________________________

Or

Signature of legally appointed guardian _______________________________________

Date: __________________

Please note parents should sign for minors.

The referral form can be completed electronically. Please print consent form, fill out manually, and scan. Return both to yvonne@yvonnekesselring.com.au.