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Amelia Slater is a seasoned professional with over 20 years of experience in the field of counselling, youth and community development, and social work.

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0422 035 204

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amelia@ameliaslater.com

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PO Box 70, Numurkah VIC 3636

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Referral Form

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Referral Form

Referral Form

Anyone can make a referral. At Amelia Slater Community Wellbeing we provide a broad range of professional Social Work services to the local community in Numurkah and surrounds specialising in rural and regional health and well-being.

Additionally, we provide telehealth support to those who are unable to travel. We further specialise in supporting passionate, creative adventurers with ADHD and Autism.

Amelia has a Ba in Human Services and Ma in Social Work and is specially trained in Youth Work practice and is a certified Autism Coach and ADHD Coach.

She has also undergone training in Women’s Circle facilitation, Nature-based therapies, Creative therapies, focussed psychological strategies and NDIS assessments such as functional capacity and adapted living skills.

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 assessment when support begins with us.

Alternatively, you can download the referral form and email it to us at amelia@ameliaslater.com

Person Information

First Name *

Last Name *

Email Address *

Phone Number *

Referrer Information

Referrer Name *

Referrer Last Name *

ReferrerEmail Address *

Referrer Phone Number *

Referrer's Organisation

Referrer's Relation to Client

Services Required

What services can we provide you? *

Mental Health Support Nature-based Therapies Autism Support Employee Assistance

NDIS Support Social Support Youth Services Counseling

Creative Therapies ADHD Support Education Services Professional Social Work Services

ADA Compliance

Please provide more information about other services

Please provide more information *

Has the person provided consent for this referral? Yes No

Person's Preferred Contact Method Phone Email Text Message

Does the referrer require a progress report? Yes No

If yes, when is it needed?

Additional Comments

By submitting this referral, you consent to this information being shared with the relevant health professional. You may revoke this consent at any time. Confidentiality and Privacy Notice: At Amelia Slater Community Wellbeing, we are committed to protecting the privacy of our clients and referrers. The information collected in this referral form will be used solely to facilitate the referral process and provide the necessary services to the client. We adhere to the Privacy and Data Protection Act 2014 (Vic) and the Health Records Act 2001 (Vic), which require us to manage personal information responsibly and ensure it is kept secure. Client Consent: By completing this referral form, you confirm that you have obtained the consent from the client to disclose their personal information for this referral. Storage and Access: All personal information collected will be stored securely and only accessible to authorized personnel. Disclosure: We will not share or disclose personal information to third parties without prior consent unless required by law. For further information about how we manage personal information, please email us at admin@ameliaslater.com

Acknowledgment of Country

Community Wellbeing acknowledges Aboriginal and Torres Strait Islander people as the Traditional Custodians of the land upon which we practice and recognises that sovereignty has not yet been ceded. We pay respect to Elders, past, present and emerging and support a Treaty.

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Diversity & Equity

Community Wellbeing is a safe, inclusive service provider that upholds social justice values towards equity and honours community diversity.

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Contact Details

Feel free to contact us. We look forward to hearing from you!

PO Box 70, Numurkah VIC 3636
amelia@ameliaslater.com
0422 035 204

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