Garin College Counsellor Referral Form
This form will remain confidential between you and the Garin College Counsellors.
1. Student Name
2. Year Level
New Zealand European
4. Are you self-referring or referring for someone else
Self - referring (please go to question 8)
Referring for someone else (please go to question 5)
5. If you are referring for someone else, what is your relationship with that student
Other Family Member
6. Has the student you are referring for given you permission to refer them to the service? (if possible please try to get permission from them)
7. If you are referring someone else, please include your name and phone number so one of the counselling team can contact you to discuss this referral further.
8. What is your preferred form of contact?
Email (you must check your emails on a regular basis for this form of contact)
Being called to the office by the office staff
9. How would you rate the level of urgency you, or the person you are referring, needs to see a counsellor?
10. What is the nature of the reason for the referral?
Alcohol and Other Drugs (AOD)
Food, Housing, Finances
Self Harm/Eating Disorder
A copy of your responses will be emailed to the address you provided.
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