Please note this form is NOT for referrers. If you are wanting to make a referral for a client please call (03) 9663 6733, or fill out this form and email it to us.

Please fill out the following form to express interest in counselling and family services.

If you are in crisis and in need of urgent support please call Lifeline on 13 11 14.

If you are interested in attending a group or seminar please sign up here.

Please note: We do not provide the following services: Psychiatrists (can’t provide referrals), Legal Advice (we will refer you to Family Law Courts or Legal Aid), Mediation, Diagnostic assessments & Court Reports. Only provide your email if you consent to us emailing you. You WILL receive an auto receipt to this email address when you complete this form.

We are currently experiencing a high volume of registrations so please allow 5 working days for us to contact you.

Client Self Referral Form

    [text your-postaddress id:your-postaddress placeholder "Please fill-in if different from where you live" autocomplete:address-line1]

    MobileHome or Work PhoneSMSEmail

    SMSVoice mailEmail