Make a Referral

About Us
Services
1800 Respect – 24 Hour Support
Contact Us

How to refer

We are happy to accept self-referrals, or referrals from other agencies where consent has been obtained. Please complete the referral form below.

*Some services may require a referral from a General Practitioner. Once we have received your referral, we will contact you to support you with this process.

*lf you require assistance completing the referral form, please call us on (07) 4153 4299 Monday to Friday, between 8:30 am — 4:30 pm.

For mental health support outside of business hours, please contact

Lifeline Australia (Crisis Support) on 13 11 14 — 24 Hours
Lifeline Crisis Chat — 24 Hours

Should you require assistance relating to sexual assault or sexual abuse outside of business hours, please contact:

1800-RESPECT (1800 737 732) — 24 Hours
1800-RESPECT Online Chat at http://www.chat.1800respect.org.au/#/welcome

Client Details

Referral Date

Name

First Last

Date of Birth

DD slash MM slash YYYY

Age

Address

Gender

Male

Female

Other

Other Gender

Contact Details

Phone

Mobile

Parent / Guardian / Carer Information

(For children 15 yrs & under)

Name

First Last

Contact Details

Relationship to Child

Have you received the vaccination for COVID-19?

Yes

Is it safe to send mail to this address?

Yes

Is it safe to send SMS reminders to this number?

Yes

Cultural Information

Aboriginal

Torres Strait Islander

Both

Neither

CALD

Would you like to be assisted by our Aboriginal Cultural Liaison Officer?

Yes

Do you require an interpreter

Yes

Is there a current DVO in place?

Yes

Is there a current Parenting Plan in place?

Yes

Is there a current Family Law Court Order in place?

Yes

If yes, please provide a copy

Max. file size: 32 MB.

Have you attended this service before?

Yes

How did you hear about us?(Required)

Please Specify

Who was the previous counsellor?

Referral Details

Is this a Self-Referral?

Yes

Is this a Bumblebees Program Referral?

Yes

Referring Person

First Last

Organisation/Agency

Contact Details

Phone

Mobile

Would you be interested in any of our programs?

Yes

If Applicable

Mental Health Care Plan?

Yes

Medicare Number

Client Reference

Expiry Date

NDIS Referral

Yes

If yes, please provide a copy of plan

Max. file size: 32 MB.

NDIS Number

Plan Dates

Plan Manager Details

(If Applicable)

Reason for Referral

Untitled

Please be aware that Phoenix House will only retain the referred persons details on file. All other information regarding another person’s information will be suppressed from this referral and is not permitted into case notes without their permission. This is to keep within the Privacy Act 1988.