Person requiring counselling

First Name *

Last Name *

Address

Date of Birth *

Identity *

Pronouns

Person Amity will contact to book an appointment - this may be different from client seeking counselling

Contact Name *

Contact Number *

Relationship To Person Seeking Counselling *

Is the person seeking counselling incarcerated? *

YesNo

*Interpreter Services - Amity does not cover the cost of interpretation services. If the client requires an interpreter, please arrange this prior to the appointment. Please note many interpreter charges still apply in cases of non-attendance.

Consent from the person requiring counselling

Does the person requiring counselling (client) consent to being contacted by Amity? *

Yes No

Does the person requiring counselling (client) consent to this referal? *

Yes No

Does the person requiring counselling (client) consent to the booking details of their first appointment being shared with the referrer: *

YesNo

Client to Sign - *Signature essential *

Draw signature|Type signatureClear

Type Name *

Date signed *

Brief information regarding person requiring counselling

Reason For Referral *

Referrer's details

Name *

Agency/Practice Name *

Contact Number *

Email *

Save and Complete Later