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About
Community & Health Education
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Get Involved
- News & Upcoming Events
- Job Opportunites
Contact

Information

at your

fingertips.

Referral Form.

Please find below our electronic referral form for service providers. If you are looking to self refer to Allambee for counselling support or to access our Women's Health Medical Service please contact us directly on (08) 9535 8263 to discuss further with our friendly team.

Note: This referral form is not to be used in replacement of crisis services. If you or your client are in crisis please contact 000 or view our list of 24/7 services available here

Please find a copy of the adult referral form for download here, child referral form here and consent form here

Our referral form is below. Please note there are eligibility/exclusion criteria. If unsure, or would like to consult with our team, please contact us on 9535 8263.

Referral Form

Referrer Agency or Service:

Referrer Contact Person:

Referrer Telephone No:

Referrer Email

Fax No:

Sign & Date

Client Surname:

Client Given Names:

Client Date of Birth:

Client Gender:

Client Pronouns:

Client Telephone No:

Client Email:

Client Address:

Client Cultural Details:

Referral Reason

Sexual Violence Counselling

Family Domestic Violence Counselling

Women's Health Counselling

Unplanned Pregnancy

Perinatal

Safety Information

Safe to contact via phone

Safe to leave a voice message

Safe to contact via email

Safe to send an SMS

Agency's Current Involvement With Client:

New client (not yet engaged)

Past client

Existing client

Presenting Issue/s

Mental Health Assessment/ Psychiatric Assessment/ Mental Health Symptoms

Low Mood

High Mood

Anxiety/Worry

Panic Attacks

Sadness/Depression

Anger/Irritability

Energy (+ / -)

Sleep Changes (+ / -)

Appetite Changes (+ / -)

Avoidance

Nightmares

Flashbacks

Concentration ( - )

Negative Self-Talk

Further Information

Medication (Please include dose, duration)

Substance Use (If Applicable - Please describe substance, dosage, frequency, pattern of use and current or past use)

Relevant Personal, Family and Medical History

Recent Precipitants or Stressors:

Family

Relationships

Financial

Accommodation

Employment

Unplanned Pregnancy

New Baby

Other

History of Violence/Criminal Charges?

Does the Client have a VRO?

VRO interim order

VRO final order

If applicable, the VRO is against (Name & Relationship to client)

Harm to Self:

Low

Moderate

High

Harm to Others:

Low

Moderate

High

Please describe risk (plan, previous attempt, lethality, intent, means, duration, hopelessness, substance abuse, psych disorder, pain, loss, Perinatal etc)

Safety Plan: Has a safety plan been developed with the client/family in relation to:

risk of FDV from perpetrator/s

risk to self from suicide/self-harm

risk to others from client

Please provide details of the safety plan:

Other Agencies Involved (Current & Previous - Please include contact person, telephone no and dates of involvement)

Are the currently involved agencies/ services aware of our referral? (Please attach reports if available)

Yes

N/A

Is usual GP aware of referral?

Yes

Has no GP

GP is referrer

GP Details

Contact No.

Has Client Provided Consent to be contacted by Allambee? (Please email or attach copy of signed consent form)

Yes

Additional Details/ Reports/VRO interim/finalised orders

Upload File

Have you attached a signed consent form?

Yes

Thank you for submitting a referral us.

If you would like to discuss this referral further please contact us between 8.30am - 4.30pm on (08) 9535 8263.
Client will be contacted by phone for the Allambee triage assessment.
Referrer will be contacted if Allambee is unable to contact or engage the client.
Referral will not proceed if consent form is not completed and attached. (If this was missed please download the Consent Form and submit to referrals@allambee.org.au with the subject area marked "Consent Form Referral Clients Name"

There was an error in submitting your referral.

Please download the referral forms and submit to referrals@allambee.org.au or fax to 9535 3869 with subject area marked “referrals”.

Adult Referral Form : here

Child Referral Form : here