EmailMeForm
Oogachaga Client Referral Form
This form will be treated as a confidential record when it has been completed and submitted to Oogachaga.
You will be contacted within the next 3 to 5 working days with further details about your client referral. A copy of the referral form will be emailed to you as an acknowledgement. Please check your inbox and spam folder.
Thank you.
Case Manager
email: counselling@oogachaga.com
Note: The asterisk (*) refers to mandatory fields.
1. Referred By
Referral Date
*
DD
/
MM
/
YY
Please key in today's date as the date of referral.
Referral agency
*
Referral staff name
*
Designation
*
Contact number
*
Email
*
Please repeat email
How did you know about Oogachaga?
*
Please select
Oogachaga staff / volunteer
Oogachaga event
Oogachaga website/ social media/ publicity
Colleagues
Friends
Family / Significant others
Other sources
2. Client Information
Client's full name
*
Client's chosen name (how should we address the client in person)
*
Contact number
*
Alternative contact number
Email
Please repeat email
Sexual orientation
*
Please select
Gay
Lesbian
Bisexual
Questioning (Unsure)
Heterosexual (Straight)
Other
Current gender identity
*
Please select
Man
Woman
Transgender Man
Transgender Woman
Nonbinary
Other
Client's gender pronouns (how should we address them appropriately?)
*
He/ Him
She/ Her
They/ Them
Other
Date of birth
*
DD
/
MM
/
YYYY
Nationality
*
Ethnicity
*
Religion
Relationship status
Please select
Single
Same Sex Relationship
Opposite Sex Relationship
Same Sex Marriage / Partnership / Civil Union
Opposite Sex Marriage
Divorced / Separated
Widowed
Other
Occupation
*
Highest education level
*
Please select
Primary / Elementary
Secondary / High School
ITE / Technical / Vocational
Pre-U / Junior College
Polytechnic
University
Others
Gross monthly income
*
Please select
< $1000
$1000 - $2000
$2001 - $3000
$3001 - $4000
$4001 - $5000
> $5000
3. Reason for Referral
Briefly describe the issue(s) presented by the client.
*
Accommodation/ shelter
Disability
Drug addiction
Other addiction(s)
Elderly/ eldercare
Employment
Family-related
Gender identity
Marital
Mental health
Relationship (same sex)
Relationship (opposite sex)
School/ teens
Sexual health
Sexuality
Sexually transmitted infections (including HIV)
Violence
Others, please specify:
What type of counselling does the client need?
*
Please select
Individual
Couple
Family
What is client's preferred language?
*
English
Mandarin
Other
How comfortable do you think the client is with their sexual orientation/ gender identity?
*
Please select
Very comfortable
Comfortable
Uncomfortable
Very Uncomfortable
Not Sure about client's comfort level
4. Additional Information
Is the client informed about Oogachaga, and given their consent to be referred?
*
Yes
No (please obtain consent from client first)
Please provide us with more information about the client, by uploading an attachment (eg: Social Report, Case Summary).
*
Add File
[Maximum file size: 5MB]
What follow-up action(s) will your agency be taking with the case after referral to Oogachaga? (please tick as many as applicable)
*
Continue case management
Continue counselling sessions
Continue with other programmes/services
Close/ discharge/ terminate case
Other
Is your client currently under any form of financial assistance or in financial need? If yes, please provide brief details.
*
No
Yes
Is there anything else you would like Oogachaga to know about the client?
By submitting this form, I give my consent for Oogachaga to collect, use and disclose the information for confidential and non-commercial purposes only, in accordance with the Personal Data Protection Act 2012.
*
I agree.
