Counselling and Wellbeing Intake Referral

Gateway Health offers professional and confidential counselling and mental health services provided in safe, supportive and non-threatening environments to support the health and wellbeing of individuals, families, and children.

All Referrals are Confidential

Please note: Our Counselling and Wellbeing referrals and appointments are managed via a waitlist.
Each program has it's own eligibility criteria which we will discuss during our first contact.

Please select your preferred service *

What is your role or relationship to the person being referred? *

Please specify

Referrer Details

Full Name *

Contact Phone Number *

Email Address *

Organisation Name & Address

Does the person you are making the referral for give consent for this referral? *

Will anyone under the age of 15 years be participating in service? *

If yes, does the Primary Parent/Guardian give consent for this referral?

Parent/Guardian Details

Full Name (Primary Contact) *

Contact Number *

Email Address *

Full Name (Secondary Contact)

Contact Number

Email Address

Referral Details

Referral Date

Reason for Referral - Please give as much detail as possible *

Are there any Risk or Safety Concerns? *

Are there any current legal, family court, or protective orders in place? *

Please provide a brief description

Please provide further details

Please attach a copy of GP Mental Health Plan (If available)

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Please attach a copy of any relevant documentation e.g. risk & safety assessments or reports

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Registration Form

Client Details

Your Details

Have you been a client at Gateway Health before?

Has the referred person received a service at Gateway Health before?

Full Name *

Preferred Name

Preferred Pronouns

Date of Birth *

Contact Phone Number *

Email Address *

Home Address *

Street Address *

City *

State *

Postcode *

Please provide an alternative Safe Contact Option

Sex *

Sex assigned at Birth *

Do you identify as part of the LGBTIQA+ community?

Gender Identity *

How would you like us to record your Gender Identity?

First Nations Status *

Name of Mob

Country of Birth *

Nationality *

Main Language Spoken at Home *

Is an Interpreter Required? *

Did you come to Australia as a refugee or asylum seeker? *

Year Arrived

Main Communication Used *

Please specify

Main Source of Income *

Concession Card Type *

Do you have a Medicare Card? *

Medicare Card Number

Medicare Card Code

Expiry Date

Living with a Disability?

Please provide further details

NDIS Number

Are there any needs/preferences that would assist you with accessing this service?

Household Details

Living Arrangements *

Please specify

Accommodation Setting *

Please specify

Are there any children in the household?

Emergency Contact Details

Full Name *

Contact Number *

Relationship to You *

Relationship to Client *

YesNo

Registration Form

Additional Family Member #1

Relationship to Previous Family Member

Has this Additional Family Member been to Gateway Health before?

Full Name *

Preferred Name

Preferred Pronouns

Date of Birth *

Contact Phone Number *

Email Address *

Does this person live at the same address as the previous family member? *

Home Address *

Street address *

City *

State *

Postcode *

Please provide any further details *

Please provide an alternative Safe Contact Option

Sex *

Sex assigned at Birth *

Does this person Identify as part of the LGBTQIA+ community?

Gender Identity *

How would this person like us to record their Gender Identity?

First Nations Status *

Mob Name

Country of Birth *

Nationality *

Main Language Spoken at Home *

Is an Interpreter Required? *

Did this person come to Australia as a refugee or asylum seeker? *

Year Arrived

Main Communication Used *

Please specify

Main Source of Income *

Concession Card Type *

Does this person have a Medicare Card? *

Medicare Card Number

Medicare Card Code

Expiry Date

Does this person live with a disability?

Please provide further details

NDIS Number

Are there any needs/preferences that would assist this person with accessing this service?

Household Details

Living Arrangements *

Please specify

Accommodation Setting *

Please specify

Emergency Contact Details

Full Name *

Contact Number *

Relationship to You *

Relationship to Client *

YesNo

Registration Form

Additional Family Member #2

Relationship to Previous Family Member

Has this Additional Family Member been to Gateway Health before?

Full Name *

Preferred Name

Preferred Pronouns

Date of Birth *

Contact Phone Number *

Email Address *

Does this person live at the same address as the previous family member? *

Home Address *

Street address *

City *

State *

Postcode *

Please provide any further details *

Please provide an alternative Safe contact option

Sex *

Sex Assigned at Birth *

Does this person identify as part of the LGBTQIA+ community?

Gender Identity *

How would this person like us to record their Gender Identity?

First Nations Status *

Mob Name

Country of Birth *

Nationality *

Main Language Spoken at Home *

Is an Interpreter required? *

Did this person come to Australia as a refugee or asylum seeker? *

Year Arrived

Main Communication Used *

Please specify

Main Source of Income *

Concession Card Type *

Does this person have a Medicare Card? *

Medicare Card Number

Medicare Card Code

Expiry Date

Does this person live with a disability?

Please provide further details

NDIS Number

Are there any needs/preferences that would assist this person with accessing this service?

Household Details

Living Arrangements *

Please specify

Accommodation Setting *

Please specify