Self-Referral Form

Essential Eligibility Criteria for Counselling

Are you an adult AGED (18+) who has been subjected to historical childhood sexual abuse? OR *

Are you an adult impacted by someone else’s disclosure of childhood sexual abuse (for example: family member, partner, friend or other supportive person)? *

Do you currently reside within the Perth metropolitan area? *

If "No", Please call our office on (08) 9443 1910 to discuss alternative service options

I understand that Phoenix is unable to provide services to individuals who have perpetrated or been convicted of child sexual offences. *

Are you currently involved in any court matters? *

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

I understand that Phoenix is not a crisis service. I know I can visit the Phoenix website for crisis support options.

Reason For Seeking Counselling

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

I am an adult (18+) who was subjected to sexual abuse in childhood.
I am a supportive adult (non-offending family member, partner, friend) impacted by a disclosure of childhood sexual abuse.

Client Information

We ask these questions to support your safety, comfort and accessibility needs. Your identity and cultural background is important and helps us provide culturally safe, inclusive, affirming and respectful support. Please indicate any identities that feel meaningful for you (tick all that apply):

Client Name *

First

Last

Date of Birth *

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?

Identity & Cultural Background

Aboriginal and Torres Strait Islander Identity *

Yes, Aboriginal
Yes, Torres Straight Island
Yes, both
No
Prefer not to say
Other - Self Describe

Do you identify as Aboriginal and/or Torres Strait Islander?

If "Other", Please tell us more

Please tell us more

Please describe your Cultural and Linguistic background below: *

How would you describe your cultural or ethnic background?

Is English your preferred language for receiving support? *

If "No", please tell us your preferred language:

Please tell us more

Gender Identity *

Woman
Man
Non-binary
Gender diverse
Prefer not to say
Other - Self Describe

Your identity is important and helps us provide culturally safe, inclusive, affirming and respectful support. Please indicate any identities that feel meaningful for you (tick all that apply): How do you describe your sexual orientation?

If "Other", Please tell us more

Please tell us more

Preferred Pronouns

Please tell us more

LGBTQIA+ Identity *

Asexual
Bisexual
Gay
Lesbian
Pansexual
Queer
Straight / heterosexual
Prefer not to say
Other - Self Describe

If "Other", Please tell us more

Please tell us more

Household / Family Structure *

Single
Couple
With Children
No Children
With non-child dependents
Extended family
Kinship care / community care
Other

If "Other", Please tell us more

Please tell us more

Have you received support from Phoenix before (including from the former Incest Survivors’ Association ISA) ? *

If Yes, approximately what year/s did you attend?

Other Agencies Involved

If there are other supports in your life, you’re welcome to share them here

Please list any agencies or services currently involved in your care or supporting your wellbeing: *

Please tell us more

Please tick the boxes below that you feel are relevant for you, in addition to your primary reason of seeking support for historic child sexual abuse. The following helps Phoenix counsellors to understand some of the challenges you may be dealing with.

Life Context, Challenges & Strengths

These questions help us understand what is happening for you right now, so we can offer the most supportive environment possible.

Recent Life Changes *

Loss of a family member or significant person
Relationship changes or conflict
New relationship or major milestone
Changes related to pregnancy or birth
Accident or injury
Miscarriage / abortion / still birth
Health challenges (self or loved-one)
Housing or employment changes
Mental health challenges
Started a new job
Becoming a carer
Workplace concerns e.g. bullying, harassment
Self-harming
Moving home, job or location
Other

Please select any of these changes that apply in the last 12 months.

If selected "Other" please explain below

Please tell us more

Other Challenges or Concerns *

Depression
Anxiety or Stress
Anger or emotion regulation challenges
Self harm
Eating or body image concerns
Domestic or family violence
Sexual violence
Living or welfare challenges
Work or study related stress
Pornography or sexual behaviour concerns
Low self-esteem or confidence
Trauma impacts
Grief or loss
Relationship challenges
Substance use
CPTSD or PTSD
Disability-related impacts
Health concerns
Other
None

Please select any that resonate with your experience.

If selected "Other" please explain below

Please tell us mroe

Lifestyle / Living Arrangements *

Living alone
Living with partner
Caring for children under 5
Caring for children over 5
Living with parents / guardian
Living with family / friends
Full time carer
Shared accommodation
Temporary accommodation
Living in institution / hospital
Other

Support Services Previously Used (related to trauma impacts): *

GP
Counsellor
Psychologist / Psychotherapist
Outpatient care
Inpatient care
Psychiatrist
Mental Health Nurse
Other
None

Have you been prescribed any medication for trauma‑related impacts? *

If yes, please indicate the type of medication

Antidepressants
Anti-psychotics
Anxiolytics / Hypnotics
Other

Name of medication if known, and any further information

Please tell us more

Additional Health Information of relevance

Please tell us more e.g. how a health condition is being managed (e.g. ADHD, epilepsy, diabetes, other chronic conditions)

Access & Support Needs

We want to make your experience safe and accessible, and to understand any support you may want and/or need.

Do you live with a disability, long term health condition, or access need? *

Yes
No
Prefer not to say
Other - Self Describe

If selected "Yes" or "Other", could you please help us understand by providing some background information so we can support you better:

If you are living with a disability, please share anything that would help us support you better.

Which of the following access needs would support you best? (tick all that apply)

Interpreter
Support person attending
Wheelchair access
Therapy support animal
None
Other access needs

Other

Please tell us more

Client Consent Form - OPTIONAL at this stage

Phoenix requires 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

Do you give consent for Phoenix to obtain and/or share information with relevant professionals if required? *

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? *

From a friend
From a family member
From another organisation
From your GP or other health professional
From searching the internet
Other

Other

Please tell us more

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 Eligibility Criteria for Counselling

Reason For Seeking Counselling

Client Information

Identity & Cultural Background

Other Agencies Involved

Life Context, Challenges & Strengths

Access & Support Needs

Client Consent Form - OPTIONAL at this stage

Please Note

Referral Source

Thank you

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