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Counselling Referral Form

Do you need individual counselling with a specialist therapist?

Submitting a Referral

All requests for counselling start with a Referral. Anyone can make a Referral – a medical referral is not required.

Please ensure you have the following information before starting:

details of client
guardianship information
referrer details
details for primary contact person
client’s type of disability and health concerns, and
reason for the referral.
NDIS information, if applicable, would be really helpful too.

Referrals are reviewed when they arrive to ensure we are the right service provider for you, or if we can help in the immediate with resources or telephone support. Thereafter, Referrals join our waitlist and you will be advised when a counselling spot becomes available.

Please contact SECCA for further information about our counselling service or if you require a hard copy of SECCA’s Referral form.

Please note: Due to high demand and the impact of COVID 19, SECCA has a wait list for counselling.

Client Details

Client's First Name

Client's Last Name

Gender

Preferred pronouns

Sex recorded at birth

Date of Birth

Do you identify as Aboriginal or Torres Strait Islander? (required)

Yes No Unsure / Prefer not to say

Are you with in a CALD community? (required)

CALD is an abbreviation for Culturally and Linguistically Diverse, and is commonly used to identify people who have a unique cultural background in comparison to the dominant Anglo-Australian culture.

Yes No Unsure / Prefer not to say

Main language spoken

Client's Street Address

Client's suburb

State

Postcode

Is your postal address different to above? (required)

Yes No

Client's Email Address

Leave blank if client does not have own email address

Client's Phone Number

Leave blank if client does not have own number

Client's Mobile Number

Leave blank if client does not have own number

NDIS Funding

SECCA has worked hard to ensure that the introduction of the NDIS is as seamless as possible. For information on accessing SECCA’s services under NDIS funding please follow the link.

Learn more about NDIS

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John struggles to engage with people because of his background and disability. He was referred to SECCA for help with setting boundaries and developing skills to build healthy relationships.

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