Counselling Referral Botany and Golflands Campuses

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

Please note that the details of this form will be confidential to the counselling team.
PLEASE NOTE- NEW REFERRALS WILL ONLY BE SEEN AT THE START OF TERM 2 AS MRS BRITTEN IS AWAY FROM 10 APRIL TILL THE START OF TERM 2.

If your request is urgent, do speak to a trusted adult or call 1737 or Youthline on 0800 376 633. If it is not urgent, please do put your referral in and one of the team will see you in Term 2.

Take care.

Name of student being referred for counselling

Year Level

Year 0-6

Year 7

Year 8

Year 9

Year 10

Year 11

Year 12

Year 13

Clear selection

Referred by...(Please put your name if you are referring someone for counselling. If you are requesting counselling for yourself just put "self")

Because...

Urgency?

Not urgent

Extremely Urgent

Clear selection

Submit

Clear form

Never submit passwords through Google Forms.

This form was created inside of Elim Christian College. Report Abuse

Forms