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Hope Counselling

Email Enquiries

Referral for Refugee Counselling

Please fill in the form below to refer a refugee for counselling with us. Fields marked with an asterix (*) are mandatory. If the information is unknown or not applicable, please specify as such. All information provided is strictly confidential.

Hope Counselling is not a crisis service.

For urgent assistance, please contact Lifeline on 13 11 14 or the Mental Health Line 1800 011 511.

Referrer Details

Name

Contact Number

Email

Referring Organisation

Organisation Address

Client Consent

Has the client consented to being referred to Hope Counselling? * Required

Yes

No

If the client is under 16, has parental/carer consent been obtained? * Required

Yes

No

Not Applicable

Client Personal Details

Family Name

Date of Birth * required

Given Name

Occupation

Gender * Required

Male

Female

Martial Status * Required

Never Married

Married

De Facto

Separated

Divorced

Widowed

Unknown

Street Address

Suburb

Postcode

Contact Number

Email

Country of Birth

Ethnicity

Religion

Person to Contact

Relationship to Client

Contact Number

Client Residential Status

Date of Arrival * required

Visa Subclass

Reasons for referral

Thank you

Hope Counselling - ABN (Lara Jane Blair) : 98 892 738 077

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