Referral - Flowstate Margaret River Inc

During Flowstate’s surf therapy programs, we will learn how to use the ocean as a resource to support your mental and emotional well-being, improve your surfing and ocean skills, have open conversations about mental health, practice coping skills and share and learn from each other.

Participant's Details

Name(Required)

Preferred Name

Date of Birth(Required)

Hidden

Age

Gender Identity(Required)

Preferred Pronouns(Required)

Do you identify as Aboriginal and or Torres Strait Islander?

Do you identify as being from a culturally or linguistically diverse background?

Participant's Contact Details

Same as Parent/Guardian

Yes

Participant's Email(Required)

Participant's Phone(Required)

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Parent Guardian Contact Details

Parent/Guardian Name(Required)

If under 18 years of age

Parent/Guardian Email(Required)

Parent/Guardian Phone(Required)

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Next Of Kin/Emergency Contact Details

Same as Parent/Guardian

Yes

Next Of Kin/Emergency Name(Required)

Email(Required)

Phone(Required)

Confidentiality and Consent

We are committed to protecting your privacy, all information and documentation will be kept secure. We will only ever share information about you if you are at risk or if we are legally requested to do so.

In order to provide a safe, positive and therapeutic experience for everyone we ask that you do not attend sessions if you are under the influence of drugs and or alcohol.

I Have Read, Understand, And Agree To The Above.(Required)

Yes

Full Name(Required)

Parent/guardian if under 18

Signature(Required)

Parent/guardian if under 18

CAPTCHA

Flowstate Surf Therapy Program Referral

Participant's Details

Participant's Contact Details

Parent Guardian Contact Details

Next Of Kin/Emergency Contact Details

About The Participant

Confidentiality and Consent