First Name: (of the person requiring counselling) *

Last Name: (of the person requiring counselling) *

DOB: (of the person requiring counselling) *

Please choose a service: *

Address

Street Address *

City

Country *

Postal Code *

Gender *

Ethnicity

Details of disabilities or additional support needs, if any.

We would appreciate it if you could share some details about the reason for the referral. However, if you prefer not to share at this time, that's perfectly fine - we will still proceed with processing your referral.

Are there any other professionals involved? (e.g. Social Work, Counsellors)

What would be your preferred day/s for counselling?

Thursday

Where did you hear about us?

Full name of person completing referral *

Phone of person completing referral *

Email of person completing referral *

Organsiation (for professionals only)

Consent and Privacy

By submitting this referral:

I confirm that the information provided is accurate to the best of my knowledge.
I understand that submitting a referral does not guarantee access to counselling services.
I understand that Rainbow Rogues will review the referral to determine suitability for the service.
I consent to Rainbow Rogues processing the information provided for the purpose of assessing and managing this referral.
Where I am referring a child or young person, I confirm that I have parental responsibility or appropriate authority to make this referral.

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