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Referrals & Intake

We are here to find the right support for our clients and their families

Please fill out the referral form below and we will get in contact with you within 3 business days. Alternatively, you can also request a referral form to fill out and send it to us via email: info@fountainofhope.com.au.

Referral & Intake Form

Please fill out as much information as possible. Thank you.

Date of Referral*
Date Format: DD slash MM slash YYYY
Referrer Details
Name*
Title First Last
Contact Details*
Relationship to client*
Client Details
Name*
Title First Last
Date of Birth*
Date Format: DD slash MM slash YYYY
Gender
Phone*
Please explain further the reason for your referral*
Please tick the reasons for referral
- Counselling for Depression, Anxiety & Burnout
- Counselling for children and adolescents
- Relationship Counselling
- Carer support
- Supervision & Mentoring
- Self Harm & Suicidality
- Body Image & Eating Concerns
- Support for Addictions i.e. gaming, drugs, gambling
- Art Therapy & Sand Tray Therapy
- Advocacy & Referrals i.e. To access a service or support
- Psychotherapy for a Traumatic Incident
- Life Skills Training i.e. Social Skills, Anger Managment
- Employment/Vocational Support
- Parenting support
- Grief & Loss Counselling
- Psychosocial Assessment
- Brief Coordination of care
- Safety planning & Referral
- Other
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Fax (02) 5747 4153

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Greater Sydney Suburbs & Online Counselling Services

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info@fountainofhope.com.au

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Fountain of Hope Social Work Support Services, acknowledges the traditional custodians of the land on which we live and work, and pay our respect to Elders past & present. Copyright © 2020 Fountain of Hope | Website by JiveWebsites.net | Privacy Policy