- Uniting WA

Children’s Counselling Service referral form

Referrer Details

By entering your details, you consent for Uniting WA to contact you for the purpose of assessing eligibility for this program
Date of refferal*
Referrer's name*
Referrer's Agency*
Referrer's phone*
referrer Email*
Does the child/young person agree with the referral to counselling?*
- Yes
- No
Family Details
Child/ young person being referred
person being referred name*
person being referred DOB*
person being referred address*
person being referred Parent's Email
person being referred parent mobile
person being referred ethnicity*
Parent/Caregiver 1

*Only one set of parent / caregiver details are required
Parent 1 name*
Parent 1 relationship*
Parent 1 address*
Parent 1 Email*
Parent 1 mobile*
parent 1 ethnicity*
Is Parent/Caregiver 1 a legal Guardian?*
- Yes
- No
Parent/Caregiver 2
Parent 2 name
Parent 2 relationship
Parent 2 address
Parent 2 Email
Parent 2 mobile
parent 2 ethnicity
Is Parent/Caregiver 2 a legal Guardian?*
- Yes
- No
Other agencies involved with the child
Other orgs/ agencies name
Other orgs/ agencies contact details*
Reason for Referral
Reason for the referral / current presenting concerns?*
Medical/Health
Please list any relevant medical/mental health information?*
Other Relevant Information
Please list any other relevant information
Goals for Counselling
Referrer’s views of why counselling would be helpful*
Parent/Guardian consent
Parent/Guardian 1
Parent / Guardian 1 please sign (type) your name*

*Only one parent / caregiver is required to give consent
I consent for Uniting WA to contact me for the purpose of assessing eligibility for this program*
- I agree
Date*
Parent/Guardian 2
Parent / Guardian 2 please sign (type) your name
I consent for Uniting WA to contact me for the purpose of assessing eligibility for this program
- I agree
Date

Children’s Counselling Service referral form

Referrer Details

Family Details

Child/ young person being referred

Parent/Caregiver 1

Parent/Caregiver 2

Other agencies involved with the child

Reason for Referral

Medical/Health

Other Relevant Information

Goals for Counselling

Parent/Guardian consent

Parent/Guardian 1

Parent/Guardian 2