EmailMe Form - Counselling Referral

Date: *

Which WHWS counselling service are you referring for?

First Name *

Surname *

Date of Birth *

Gender identity *

Home Phone *

Mobile Phone *

Email *

Preferred time for Women's Health and Wellbeing to call you *

Is it OK for Women's Health and Wellbeing to leave a message on your phone or send a letter (please check the box for yes and leave blank for no) Please provide a phone number and written method of contact so in the event one is unsuccessful we will use the other provided. *

Emergency Contact (Name & number) *

In the event a staff member has assessed that you or someone else is in danger, the emergency contact provided will be contacted, where one has not been provided WHWS will call either 000 for an ambulance or police to complete a welfare check.

Home Address *

Suburb *

Postcode *

Nationality *

Country of Birth *

Do you identify as Aboriginal or Torres Strait Islander? *

Do you identify as culturally and linguistically diverse? *

Number of Children

Children's Names and Date of Births

Do you have a carer?

Yes

No

Do you want your carer/ support person involved in your care at WHWS?

Yes

No

I understand that consent to share information can be withdrawn at any time by contacting WHWS in writing

Yes

No

How do you want your carer/ support person involved?

Referred By (you may refer yourself) *

Referrer Details (agency information including email address)

Does the client know this referral has been made for them? *

Further comments or information

I understand that if I wish to share information with a professional provider I must go to the WHWS website and complete the 'Consent to Release Information' Form

Yes

No