Client Referral Form

Please tick the issues below that are relevant to the person you are referring.  Please disclose family relationships, including any incidences of domestic and family violence, drug and/or alcohol use, known risks (e.g. suicidal ideation, self-harm, harm to others) or mental health issues etc.   Please also include below any further information related to the issues identified in the check boxes, and/or any information related to a formal mental health diagnosis including any medication prescribed.

What is your understanding of how the client has coped with / or avoided dealing with their trauma?  Please include information about their current self-regulation and self-care strategies.  Please include below any further information related to the issues identified in the check boxes and/or any information related to a formal mental health diagnosis including any medication prescribed.

• Please be aware that there may be a waitlist.
• If this is the case, we will assess the person/s at the earliest opportunity to review suitability for the service prior to their placement on the waitlist. This also allows the person/s to assess if Phoenix is a ‘right fit’ for them.
• To reduce client expenses and travel time, Phoenix provides appointments online via the internet. Online counselling from the client’s home can reduce anxiety and enhance a sense of safety. If in-person counselling is preferred then this can be provided on request.

For a list of telephone crisis, counselling and support services please go to www.phoenix.asn.au