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Referrals

Make a referral

We accept self-referrals and referrals from agencies for individuals living or working across the Gladstone and Banana Shire regions.

For more information and booking appointments:

Get in touch

Self-referrals:

EMAIL US

CALL US

1800 749 22207 4979 1456

Interpreter services available

Opening hours

Monday to Friday: 9.00am to 5.00pm

Closed public holidays

Agency referral form

If you would like to refer a client to our services, please complete our referral form using one of the following options:

Complete online using a digital form
Complete a physical form and submit via email

Digital form

Person making the referral

Preferred contact method

Client details

Is it safe to leave a message?

Dependents

Does the client have dependent/s?

Domestic and family violence

Is there any current or historical domestic and family violence?

Safety/risk assessment

Do you have any immediate concerns for the safety of your client or his/her children?

(eg. adult survivor of child sexual assault, child victim of sexual assault, or adult sexual assault survivor)

Self-harm

Is there any history of self-harm?

(e.g. cutting, eating disorders, intentional overdose, suicide attempts)

Substance abuse

Does the client have any history of drug or alcohol abuse?

Support services

Is the client currently engaged with any other support services?

Reason for referral and any other areas of concern

Privacy notification

(Australian Privacy Principle #5: Notification of the collection of personal information)

Referral received

Thank you for your referral. Our team will review it and be in touch soon.

Oops! Something went wrong while submitting the form.
Download Referral Form PDF
Please email completed forms to:

Looking for emergency contacts?

See our list of other support networks that can help you in an emergency.
Emergency contacts
Contact us to get support