Form 4 Application for Counselling

FORM 4

FORM 4 APPLICATION FOR COUNSELLING (VOCAT)

INFORMATION

1) Tribunal reference number (if known)

2) Name *

First

Last

3) Applicant's Address

Address Line 1

Address Line 2

City

State

Zip Code

4) Tribunal venue (where application lodged)

REQUEST:

I REQUEST that the Victims of Crime Assistance Tribunal make an award for counselling expenses to assist me to recover from the effects of the act of violence detailed in my application to the Tribunal, and that the counselling be provided by:

5) Counsellor's Name *

First

Last

Counsellor’s Address

Address Line 1

Address Line 2

City

State

Zip Code

Counsellor’s ABN:

Counsellor’s Telephone:

I ACKNOWLEDGE THAT:

I agree with the counselling plan set out in the counsellor's report filed in support of this application for counselling.

I have already attended (insert number of hours)

Numbers

hours of counselling with the counsellor.

I understand that after the first five hours of counselling, the Tribunal will usually only pay for counselling sessions that take place after an award of financial assistance for further counselling has been made by the Tribunal.

If, after the first five hours of counselling, I have further counselling before the Tribunal has awarded financial assistance for that counselling (tick box for relevant clause):

a) I have agreed to pay the counsellor for that counselling.

Checkboxes

b) My counsellor has agreed that I will not be charged for that counselling.

Note – if neither option (a) or (b) is marked, the applicant will be requested to file a new Application for Counselling, causing

Applicant’s Signature:

Date

Counsellor Signature:

Date

We are committed to elevating both organisational and personal health and well-being, with focus on enhancing performance and productivity.

Form 4 Application for Counselling

FORM 4

FORM 4 APPLICATION FOR COUNSELLING (VOCAT)

Quick Links

Featured Links

Contact Us / Enquire