Referral Form

Name & Pronouns:*

Gender Identity & Sexuality:

Birthday:*

Day

Month

Year

Location:*

Email:*

Phone Number:*

What type of support are you interested in?*

Individual Counselling

Professional Supervision

NDIS Capacity Building Support

Are you referring on behalf of someone else?*

Yes

If yes, please provide your contact details, relationship to the person and whether you have their informed consent for this referral:

What are the main things that you would like support with:*

Preferred method of contact (you can choose more than one):*

Text message

Phone call

Would you prefer in person or telehealth appointments?*

In Person (West End, Magandjin/Brisbane)

Telehealth (Australia-Wide)

Both

Which fee rate is applicable for you?*

Standard Fee

Concession Fee

NDIS Capacity Building Funding

Other Third Party (please state in referral details)

How did you hear about us?*

Once this referral has been submitted, our admin team will get in touch with you within business hours to discuss the next steps.

We acknowledge the Traditional Custodians of the land on which we work and live, the Turrbal and Jagera peoples. We pay our respects to their Elders, past, present, and emerging, and recognise their continuing connection to the lands, waters, and communities of this region.

We acknowledge that sovereignty was never ceded and this always was, and always will be, Aboriginal land.

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