Garin College Counsellor Referral Form
This form will remain confidential between you and the Garin College Counsellors.
Email address *
1. Student Name *
Your answer
2. Year Level *
3. Ethnicity
4. Are you self-referring or referring for someone else *
5. If you are referring for someone else, what is your relationship with that student
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.
Your answer
8. What the preferred form of contact for the person being referred?
9. How would you rate the level of urgency for you, or the person you are referring? *
Low
Extreme
10. What is the reason for the referral? *
Required
Notes or additional information
Your answer
A copy of your responses will be emailed to the address you provided.
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