Counselling Online Form *Selected Program *Name *Date of Birth *Address *Mobile *Email *Name of employer *Employer’s EAP Helpline Number/Access Code *Are you currently on a Mental Health Care Plan *Are you experiencing financial, geographical, social or any other form of hardship *Are you at risk of suicide By submitting this form, you confirm that you have given consent for this referral, including contact by a MindSpot representative by post, phone, email or SMS. You also confirm that you are aware of these services and that you meet the criteria for referral. Δ
