Self-Referral Form

Essential Referral Criteria

I am an adult AGED 18+ who is a survivor of childhood sexual abuse OR *

Yes
No

I am an adult impacted by a disclosure of child sexual abuse such as a family member, friend or significant other *

Yes
No

I live within the Perth metropolitan area *

Yes
No

I am aware that Phoenix is unable to provide services for perpetrators or convicted offenders of child sexual abuse *

Yes
No

Please tick that the following essential criteria applies to you before proceeding *

I am aware that Phoenix is not funded to provide crisis services, however, I am aware I can refer to the Phoenix website for crisis information

Ongoing Court Matters

I am involved in ongoing court matters at the time of completing this form *

Yes
No

Reason For Seeking Counselling

Please tick the box with the main reason for seeking counselling with Phoenix *

Adult who has experienced sexual abuse as a child
Adult family member, partner or significant other, impacted by a disclosure of childhood sexual abuse

Client Information

Client Name *

First

Last

Date of Birth *

Gender

F
M
Diverse

Address *

Address Line 1

City

State / Province / Region

Postal Code

Perth metropolitan area only

Email Address *

Telephone

Preferred Methods of Contact (tick all that apply) *

Telephone
Email

Mobile *

Can We Leave A Message?

Yes
No

Have you ever received services from Phoenix, previously known as the Incest Survivors’ Association ISA ? *

Yes
No

Other Agencies Involved

Please provide the name/s of any other agencies involved with your care

Specific Needs – Language, Literacy Challenges AND/OR Disability

Client Consent Form - OPTIONAL at this stage

Phoenix will require Consent to be able to share information and /or discuss your case with any other relevant services or practitioners. You are welcome to complete this Client Consent Form online here, OR during your assessment, should you proceed

I agree to the following Authority to obtain and/or release information *

Yes
No

Date of Consent to release information

Please date this form to acknowledge your Consent

I authorise Phoenix Support & Advocacy Service Inc. to exchange information with other relevant professionals or organisations.

This authority permits discussion between Phoenix and the parties mentioned below in addition to the exchange of written reports. This contact with other parties would be discussed with you prior, except in an emergency or if your safety and well-being are at risk.

I understand that I can change or cancel this authority at any time and can refuse to permit information exchange, except in the case of an emergency.

I understand that parties mentioned below will be provided with a copy of this authority before providing Phoenix with information.

If yes, I am being supported by: Please list Name, Phone Number, Address

e.g General Practitioner, Case Manager, Support Worker, Drug & Alcohol Counsellor, Psychiatrist, Other

If applicable, have you arranged childcare during the counselling sessions? *

Yes
No
Not Applicable

Please Note

Phoenix opening hours: 9:00am – 5:00pm Tuesday, Wednesday, Thursday.
The Phoenix office is closed on Mondays and Fridays.
There may be a waitlist. If so, we will undertake an assessment at the earliest opportunity to review your suitability for the service prior to placement on the waitlist. This also allows you to assess if Phoenix is a ‘right fit’ for you.
The assessment also allows you to be referred to any other support services you may need while you are on the waitlist for counselling.
To reduce your expenses and travel time, Phoenix provides appointments online via the internet. Online counselling from your home can reduce anxiety and enhance a sense of safety. If in-person counselling is preferred, this can be provided on request.
For a list of telephone crisis, counselling and support services please go to www.phoenix.asn.au

Referral Source

Can you please indicate below how you first found out about Phoenix Support and Advocacy Service? *

Thank you

Thank you for providing comprehensive information in this self-referral form.

Should you require further information or have any questions, please phone (08) 9443 1910 during business hours Tuesday, Wednesday or Thursday.

Please click the button below to submit.

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Please Note

Essential Referral Criteria

Ongoing Court Matters

Reason For Seeking Counselling

Client Information

Other Agencies Involved

Specific Needs – Language, Literacy Challenges AND/OR Disability

Client Consent Form - OPTIONAL at this stage

Please Note

Referral Source

Thank you

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