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ABOUT US
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Contact@gippslandequine.com | 0428768916
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Referral Form
SELF OR AGENCY REFERRAL FORM
Date of Referral
Is the Client Aware of the Referral?
Yes
No
Self-Referral
Not Sure
What Service is the Client Seeking
Equine Assisted Learning
Equine Assisted Psychotherapy
Khayala-mi Healing Session
Counselling - Telehealth
Counselling - In Room
Equine Healing Experience
Grief Support
Other
Name
Date of Birth
Gender
Male
Female
Transgender
Non-Binary/Non-conforming
Prefer not to Say
Address
Email
Phone
Parent/Guardian
Contact Phone
Referrer Details
Name
Orgainisation/Position if Applicable
Address
Email
Phone
Current Diagnosis/Disorders:
Reason for Referral:
Other
Who will be responsible for paying for sessions?
Available Days
Monday AM
Monday PM
Tuesday AM
Tuesday PM
Wednesday AM
Wednesday PM
Thursday AM
Thursday PM
Friday AM
Friday PM
Saturday AM
Wait List
Yes
No
NDIS CLIENTS ONLY
NDIS Participant
Yes
No
Not Sure
Awaiting
NDIS No.
NDIS Plan Start Date:
Number of Sessions Required:
When are the Sessions Required:
Twice Weekly
Weekly
Fortnightly
Not Sure
AGENCY FUNDED CLIENTS ONLY
Number of Sessions Allocated
1
2
6
8
10
12
Do You Require a Quote or Invoice
Quote
Invoice
Name of Agency Paying the Invoice:
Email Address for Invoicing:
BEFORE YOU GO...
How did you Hear About Us
Word of Mouth
Advertising
Facebook
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Local Paper
Local Flier
Other
Other
Send
Gippsland Equine Counselling & Wellness 15 Lowrys Road, VIC, 3959 Phone. 0428 768 916
