Make a referral to WHW

You can make a referral to our:

Please contact intake on (03) 9689 9588 if you need further information or have a query about the form.

General referrals

Please submit the form below. If you have difficulties, you can download the form and email it to fvassist@whwest.org.au. Please remember to save any changes before emailing the form.

If you have any queries or would like to speak to our intake team, please call (03) 9689 9588 or email fvassist@whwest.org.au.

Children’s counselling referrals

To make a referral to Women’s Health West’s children’s counselling team, please download and complete the referral form below (pdf) and email it to counselling@whwest.org.au.

If you experience difficulties opening the form, download it, save it, and open it from Adobe Acrobat Reader.

Alternatively fill out the form directly below:

Children's counselling referral form (1)

  • Referral Form - Children and Youth Counselling

    Women's Health West counselling program provides counselling interventions for children, young people and families who have been impacted by family violence in the western metropolitan region. Guidelines for referral to the program: The child or young person is aged between 0 and 17 years. The main reason for counselling is recovery from the impacts of family violence. The child or young person is not residing with the perpetrator of family violence. The child or young person's mother or predominate care giver has access to support and can engage in the counselling process.
  • Date Format: MM slash DD slash YYYY
  • Mother/Carer's Details

  • Child/Young Person's Details

  • Further Information

  • Behaviour/Presentation of Child/Young Person.

    Please select any concerning behaviours in the child / young person from the list below.
  • Your description should answer: What does the behaviour look like? How often does it occur? How would you describe the severity of the behaviour?
  • Child's experience of Family Violence.

  • Legal Details

  • Please note that WHW are unable to provide reports for Family Court
  • Additional Information

  • Other Agencies

    List any other agencies involved with family and provide contact details below:
  • Name of worker and agencyContact detailsReason for involvement 
  • Name of worker and agencyContact detailsReason for involvement 
  • Name of worker and agencyContact detailsReason for involvement 
  • Please attach an up-to-date risk assessment with any other relevant information and forward the referral to WHW - email: counselling@whwest.org.au. Phone: 9689 9588