Referral Form

By completing this from, your referral will be submitted for assessment by Horizon Counselling. Please note: Horizon Counselling is not a crisis or acute mental health service. If the person being referred is at high risk of suicide or harm to themselves or others please contact emergency services on 000 or Lifeline on 13 11 14.

Confidentiality is of the utmost importance to us and and keeping personal information safe is our priority. This information will not be shared with anyone unless they give consent or there is and imminent risk of harm to them or someone else. For more information visit our Privacy Policy.

If you would like to email or print a copy of this form for your records, do this before sending.

Date

Referrer's Name

Referrer's Job Title

Referrer's Organisation Name (Please enter NA if familiy member or carer)

Referrer's Email

Referrer's Phone Number

Name of person being referred

Date of Birth

Age

Gender

Aboriginal or Torres Strait Islander

Yes No

Country of birth

Address of referred

Phone number of referred

Email of person referred

In case of emergency please contact

Emergency contact phone

Relationship

Emergency contact address

Reason for referral

Does the person have an existing GP?

Yes (If yes please provide details) No

GP Phone number

GP Name and Practice

CONSENT - The person being referred, is aware of this referral and has given consent

Yes No

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6 George Main Road, Victor Harbor SA 5211. (Opposite Victor Harbor Police Station)

Mon, Thurs and Fri 9am – 5pm BY APPOINTMENT ONLY

We acknowledge the Traditional Owners of the land where we work and live. We pay our respects to their Elders, past, present and emerging. We celebrate the stories, culture and traditions of Aboriginal and Torres Strait Islander Elders of all communities who also work and live on this land.