Referrals

Date of Referral

Referring Agency/Individual

Referring Agency

Individual

Referring Agency Contact Person

Skip if individual

Referring Agency Contact Phone

Skip if individual

Referring Agency Contact Email

Skip if Individual

Agency and contact person

Agency Contact details

Agency referrals only

Client’s Goals for Counselling

Agency referrals only

Briefly describe reasons for seeking counselling and any goals for counselling that you might have. Focus on strengths and resilience where possible.

Agency referrals only - Example: "Client is seeking support to process complex trauma related to domestic violence. They have expressed a desire to rebuild emotional safety, improve coping strategies, and reconnect with community. Client demonstrates strong resilience and commitment to healing."

I confirm that the client has consented to this referral and understands that Gari Kuruma Counselling, training and coordination Centre provides trauma-informed, strengths-based support focused on safety, empowerment, and recovery.

Yes I Consent

Agency referrals only

Gari Kuruma Leadership

Wendy Brooks

Vicki Cosgrove

Ivan Dragostinov

Seeking Volunteers