EveryMan referral form

EveryMan referral form

Date received*

PERSON BEING REFERRED

Name(s) of person being referred

If you're asking for help for yourself, give your name.
If you're referring someone else, give their name.

DOB

Mobile number to contact person being referred*

Please use this format: 0400 111 222

Person's landline

Person's email address

Do they have any children?

Yes

No

Don't know

Do they identify as Aboriginal or Torres Strait Islander

or are they accepted as such in their community?

Yes

No

Don't know

PERSON MAKING THE REFERRAL

If this referral is for you, leave this section blank.

Name

If this referral is for you, just say 'me' or 'me and my partner' etc.

Agency/organisation

If this referral is for you, leave blank.

Position

If this referral is for you, leave blank.

Mobile

Please use this format: 0400 111 222.

If this referral is for you, leave blank.

Email address

If this referral is for you, leave blank.

Landline

If this referral is for you, leave blank.

Referring to an EveryMan program

if you already have one or more in mind as relevant for the person you're referring.

Please note

EVERYMAN PRIVATE is a fee-for-service alternative to our other counselling service.

NOTE 1. There is an upfront fee of $187 per hour ($170 plus GST) which will be charged at the time of booking.

NOTE 2. This service is not covered by Medicare or private health insurance providers, so you will not be able to claim benefits from either.

To get more information before you check this box, go to www.everyman.org.au/services/everyman-private

Counselling: violence (risk of using violence or recent use of violence)

Counselling: general (all other matters including being victim/survivor of violence)

Counselling: EveryMan Private ($187 ph fee-for-service counselling)

Men's Accommodation & Support Services (MASS)

Working With the Man (for men at risk of using violence with partner, ex or family)

Preventing Violence, Changing Behaviour course (12 week program)

SUPPORT REQUEST INFORMATION

Details of issues and support needs

Supporting documents attached?

Yes

No

Supporting documents details

File Attachments

Drag and drop files here or

CLIENT CONSENT

This section is for people referring someone else.

Has this referral been discussed with the person you're referring?

Yes

No

Not sure

Have they agreed to contact with EveryMan?

Yes

No

Not sure

Do you have their signed consent to exchanging information about them with EveryMan?

yes

no

IF YOU DON'T HAVE SIGNED CONSENT

and you're not a partner, family member or friend, you will need to organise this with the person being referred. There are two ways of doing this.

Option 1: Download a consent form from our website at www.everyman.org.au/referrals/

Option 2: Let the person being referred know we'll call them and make arrangements to confirm their consent. Please indicate which option you think will work best in this situation.

Please check the box for the option you think will work best in this situation.

Consent options

Option 1. Downloading form

Option 2. EveryMan to arrange

Consent notes

Send me a copy of my responses

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