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

  • Family Details

  • Child/ young person being referred
  • Parent/Caregiver 1

    *Only one set of parent / caregiver details are required

  • 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
  • *Only one parent / caregiver is required to give consent

  • Parent/Guardian 2