The Counselling Referral Form Template – Australia is offered in multiple formats, including PDF, Word, and Google Docs. These options are both modifiable and print-ready, crafted to fulfill your requirements effortlessly.
Counselling Referral Form Template – Australia Editable | PrintableSample
1. Referring Party Information 2. Client Information 3. Reason for Referral 4. Previous Treatment History 5. Crisis Risk Assessment 6. Consent for Referral 7. Preferred Contact Method 8. Special Considerations 9. Signatures and Acceptance
PDF
WORD
Examples
[Client’s Name]
[Client’s Date of Birth]
[Client’s Address]
[Client’s Phone]
[Client’s Email]
[Referrer’s Name]
[Referrer’s Agency Name]
[Referrer’s Phone]
[Referrer’s Email]
[Date of Referral]
[Detailed description of reasons for referral, including any specific concerns or issues the client is facing or goals for counselling.
[Provide any important background information that may aid the counselling professional, including relevant medical history, previous counselling experiences, or family dynamics.]
The client has given consent for this referral and understands that their information will be shared with the counselling professional. Please confirm consent here: [Yes/No].
[Note any special considerations, such as cultural or linguistic needs, or any other circumstances that the counsellor should be aware of.]
[Referrer’s Signature]
[Referrer’s Name]
[Referrer’s Position]
[Referrer’s Agency Name]
[Date of Signature]
[Client’s Name]
[Client’s Date of Birth]
[Client’s Address]
[Client’s Phone]
[Client’s Email]
[Referrer’s Name]
[Referrer’s Agency Name]
[Referrer’s Phone]
[Referrer’s Email]
[Date of Referral]
[Detailed description of reasons for referral, including any specific concerns or issues that prompted the referral and the expected outcomes of counselling.]
[In-depth background information including medical history, current medications, previous treatments, and any relevant family or social issues that may impact the client’s counselling experience.]
Client provides consent for this referral and understands that the information will be shared with the counselling professional for the purpose of assessment and treatment. Client consent confirmed: [Yes/No].
[Any further information or context that would be beneficial for the counselling professional, such as previous rapport with the client or other professionals involved.]
[Referrer’s Signature]
[Referrer’s Name]
[Referrer’s Position]
[Referrer’s Agency Name]
[Date of Signature]
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