Supporting Recovery Mental Health Referral Form (Self Referral)

Supporting Recovery provides access to ongoing trauma informed mental health support, including psychological therapies, for people who have experienced family, domestic and sexual violence. It is offered at no charge for a period up to two years and in person services are available in the Fairfield, Liverpool and Campbelltown LGAs. Click here to download the Service Brochure.

Please note, Supporting Recovery is not a crisis support service. If you are in need of emergency help, contact 000. You can also contact these organisations if your needing urgent help; 1800RESPECT on 1800 737 732 or NSW DV Line on 1800 656 463.

Supporting Recovery accepts referrals from people that live and/or work in South Western Sydney region.

If you need to speak with someone from the Supporting Recovery team about your referral, please get in touch using the contact details below:

Email: referrals@supportingrecovery.org.au
Phone: 1300 316 554

Your Details

First Name

Last Name

Address

Preferred Contact Method

Provide Preferred Contact Information (Your phone number or email address)

Is it safe to leave a message?

Date of Birth

Pronouns

Indigenous Status

Do you require an Interpreter?

Yes No

If yes to Interpreter, language required?

What are your main concerns at the moment?

Is there any additional information we need to know?

How did you hear about Supporting Recovery?

If you have selected 'Other', please provide details here

Your consent

This referral form collects information to assist our Supporting Recovery staff to help you access services you may need. By completing this form, you consent to be referred to Supporting Recovery, and give Supporting Recovery permission to contact you by the information you have provided. You understand that you can withdraw from this referral or from the referred service at any time. All information will be treated confidentially and this information, and any other information provided, will only be used for the purposes stated on the consent form (signed when you first engage with services). I understand that I can find out more about how much personal information will be collected, managed, stored, and disclosed as well as details about how to correct my information by visiting Privacy Policy webpage.

Signature

Date Signed

Referrals will be responded to within 5 business days of receipt.

I agree to the Supporting Recovery Privacy Policy.

If you are currently experiencing domestic violence and need crisis support, call 1800RESPECT (1800737732 ). If you are in immediate danger, call the police on 000.