Client Referral Form

Please fill out the online form below, by filling in each section and clicking NEXT once you have completed each part.

Referrer Contact Details

Client Details

Client Risk History

It is essential that all known risks are disclosed whether current or previous.

Please disclose all current and past risks and hazards known about the client:

Drug Use

Alcohol Use

Violent or Agressive Behaviour

Mental Health Issues

Other Known Risks

Your Wellbeing 


Hand Sanitising

We require all staff, clients and visitors to hand sanitise when entering our facility, and hand sanitiser is located at the entrance.

Face Masks

We may require you to wear a face mask when attending our programmes. This is not limited to only Government restrictions (if applicable) as we maintain our own health and safety policies and procedures. We may refuse you entry to our programmes if you refuse to comply with any request to wear a face mask.

Please note also that you may request a face mask from us at anytime if you prefer to wear one to maintain your own wellbeing

Health & Safety Compliance

Parent / Guardian Details

Please note that this person will also be the first point of contact in an emergency.

Second Point of Contact Details

Please provide a second point of contact in case we are unable to reach the primary contact in case of emergency.

To complete this referral, please hit "Send Referral Now"