Counselling Referral Form.

Thank you for considering Skylight Mental Health as your counselling provider. To get started, there’s a little bit of information we’d like to know about you in order to prepare for our work together.

If you have any questions or would like some support in filling out this form, please call Skylight Mental Health on (08) 8378 4100 to speak with a member of our Customer Relations Team.

Who is making this referral?*

I am referring myself

I am referring someone else

Referrer details:

Referrer Full Name:*

Referrer Phone Number:*

Relationship to participant:*

Referrer Email:*

Counselling participant details:

First Name:*

Last Name:*

Phone number:*

Address:*

Postcode:*

Date of birth:*

Gender:

Suburb:*

Email address:*

What is your preferred communication method?

Phone call

Email

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Do you require an interpreter?*

Yes

No

What language?*

Do you have an NDIS Plan?*

Yes

No

Which other way did you hear about us?*

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Please briefly describe some of the current challenges you face that make you want to come to counselling - e.g. anxiety, flashbacks, overwhelming emotions, etc.*

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What are you hoping to get out of counselling, what are your goals?*

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Is there anything else you think would be important for us to know?*

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Thank you for completing Skylight's Counselling Referral Form, please click "Submit Referral" below. You will receive a confirmation email shortly. Remember to check your spam/junk folder.

Submit Referral

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Counselling Referral Form.

Referrer details:

Counselling participant details:

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