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Bravehearts Support Services Referral Form


    Please complete ONE form per client
    *This question will help us to ensure we are calling our client by their preferred pronoun.
  • *If No, please be advised all Bravehearts' Consent Forms can only be completed and signed by the child's Legal Guardian.
  • *When working with children and young people therapeutically, Bravehearts believes strongly in a holistic family approach. In order to achieve the best outcomes for the child and the family, Bravehearts recommends the parent(s)/caregiver(s) also engage in our therapeutic services for education and support.
  • *Bravehearts eHealth is an online, fully confidential, video conferencing counselling, case management and support platform.
  • If yes, please provide details of each service and what support is being accessed.

  • What prompted your referral of this client to Bravehearts, and how would you like us to support this client?
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    Accepted file types: pdf, jpg, png.
  • Personal information is collected through this form by Bravehearts Foundation Ltd for the purpose of allowing us to contact you and provide services in relation to the referral. We may also disclose information obtained through this form to our contractors on a confidential basis. For more information about how we collect, use and disclose personal information, how to access or correct personal information, or to make a privacy complaint, please see our Privacy Policy at:
  • For the protection of the client's privacy, both now and in the future, if you have any other clients requesting support, please complete one Referral Form per client.