Western Wellbeing Hub - Online Referral Form

Is this a self-referral?
Yes No

What is your full name?
What is your home address?
What is your phone number?
When would you like to be contacted? (date/time)
What is your date of birth?
What is your gender?
What are your preferred pronouns?
Provide your emergency contact name and phone number
Do you identify as LGBTQIA+? Yes No

How do you identify?

Do you identify as culturally and linguistically diverse? Yes No

Do you require an interpreter? Yes No

Do you identify as Aboriginal and/or Torres Strait Islander? Yes No
Select the health care arrangements that are applicable to you: NDIS
GP Mental Health Treatment Plan
Department for Veteran Affairs (DVA)
Concession/Pension/Health Care CARD
Home/Aged Care Package
Other (please specify):

Risk Assessment

Do you have a history of self-harm? Yes No

Please provide details

Do you have current thoughts about suicide? Yes No

Please provide details

Have you recently experienced thoughts of harming others? Yes No

Please provide details

Are you currently taking any medications? Yes No

Please provide details

What are the main concerns or issues you would like support with?

Please attach any relevant documentation(s)

Choose File