Referral Form

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Referral Form

Date

YYYY

Full name

Preferred name (if different from above):

Gender:

Male

Female

Other

Prefer not to say

Clear selection

Preferred pronouns:

Ethnicity:

Year level:

N/A

Who would you like to see:

I don't mind who I see

Ashley Shaw (Counsellor, Mon-Thurs)

Michelle Grant (Counsellor, Fri)

Miss Walsh (Director of Wellbeing)

Donna Kelly (Nurse)

Clear selection

Are you currently receiving any other support? If so please outline below:

Reason for this referral:

We will respond to this referral as soon as possible.

For any mental health emergencies please contact the TACT team on 0800 277 997 or free counselling support is available by texting 1737.

Further information can also be found on our College Wellbeing website: https://sites.google.com/roncalli.school.nz/wellbeing-support/home

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