Counselling Referral - Pink Cross Australia | The Pink Cross Foundation Australia Incorporated

Referral for Counselling Services from Pink Cross Australia

This form is for you to refer another person to The Pink Cross Foundation Australia for counselling services.

IMPORTANT: This is not a crisis service. In an emergency dial 000.

Step 1 of 3: Permissions

⚠️ Important: For the safety and privacy of the referred party, your referral cannot be considered unless you check all three boxes.

The referred party understands I am contacting The Pink Cross Foundation Australia on their behalf to seek counselling services (required).

The referred party has given me explicit permission to provide their details to The Pink Cross Foundation Australia for this reason (required).

The referred party understands that if The Pink Cross Foundation Australia becomes concerned for the safety of any person we may be required to share the referred party's information with third party agencies (required).

Step 2 of 3: REFERRING party contact details

Please fill in all details. Your information is secure.

Registering as

Individual Organisation

First name

Last name

Mobile/Phone

Address

City

State

Postcode

Country

Do we have permission to contact you about this referral? (required)

Yes

How did you hear about us?

Step 3 of 3: REFERRED party contact details

Please fill in all details. Your information is secure.

Name (required)

Address (required)

Email (required)

Phone (required)

Do we have permission to contact the referred party? (required)

Yes

What is the preferred contact method? (required)

Phone

Is it safe to call? (required)

Yes

Is it safe to leave a voice mail? (required)

Yes

Is it safe to send a text message? (required)

Yes

Is it safe to send an email? (required)

Yes

What is the referred party's reason for seeking counselling from Pink Cross Australia? (required)

Is there anything else we should know?

If needed, upload a PDF, audio or video file here.