Referral Form

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Referral Form

Anyone can make a referral for services at Amelia Slater Community Wellbeing.

Please help us understand which support may suit you or the person you are referring best. The form below is not exhaustive, and we will do a thorough intake and biopsychosocial assessment when support begins with us.

If you would prefer a paper copy of this referral form, please contact us on admin@ameliaslater.com

Person's Information

Referrer Information

Services Required

What services can we provide you? (tick all that apply) *

Please provide more information about other services

Get in touch

If you're thinking about counselling, want to check whether I'm a good fit, or have questions about how I work, here's how to reach me. I read everything and reply within a few business days.

Acknowledgement of Country

I acknowledge the Yorta Yorta people as Traditional Custodians of the land upon which I practise, and the Traditional Custodians of all other lands across this continent where my clients live and work. I recognise that sovereignty was never ceded. I pay respect to Elders, past and present, and support a Treaty.

I provide a safe, inclusive service that upholds social justice values towards equity and honours community diversity.

Read our Privacy Policy and Risk Management Policy. Self-refer or refer a client via the Referral form. Existing clients can sign in to the Client Portal.

PO Box 70
Numurkah VIC 3636

Accreditation

AASW Accredited Social Worker Youth Workers Australia Member Natural Therapist Certified Member EMDR Level 2
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