Privacy Statement

Your personal information is being collected by Wyndham City Council to respond to your enquiry for counselling services.  Your information will be used and stored in Council’s Counselling Database and used to identify you when communicating with Council and for the delivery of services and information.  For further information on how your personal information is handled, visit Council’s Privacy Policy at

Criteria Checklists (required)
Reasons for Referral

Your Details and Availability

Days available (required)
Methods of counselling you are willing to receive: (required)
Which locations you would like to attend your sessions
Contact Details
Preferred Contact Number Type (required)
Preferred contact method (required)

Emergency Contact Details

Emergency Contact Details
Is this emergency contact aware of referral? (required)

Please note that if we are concerned about your safety or the safety of someone else, we may need to notify this emergency contact to help keep you or someone else safe. If you do not want that contact to be notified, you should nominate another responsible adult in your life that is available to provide support to you after hours.

If you aren’t able to provide all of this information, please call Youth Services on 8734 1355 for help to complete this form.

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