Referral Form

To access our counselling services, please complete the enquiry form below. One of our team members will contact you within 3 business days to discuss your needs and next steps.

Please note: ERICA Women’s Centre is not an emergency crisis support service.
Click here for a list of emergency contacts.

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Your Referral Form has been submitted

Thank you for your submission! We will be in touch with you soon.

First name

Surname

Phone

Email

Suburb

Postcode

Can we leave you a message?(required)

Yes No

If no, please call us on (08) 9250 2221 within our business hours (Monday – Friday, 8:30am – 4:30pm)

How are you being referred? (You may refer yourself)

If referred by an agency, please provide details of agency including email address:

If this form is being completed on behalf of a client, does the client know this referral is being made for them? (Please note we cannot proceed without client consent)