First Response Request Form

We value your privacy and we have a strong commitment to confidentiality. The information you provide on this form will be kept within Counselling Support. It will assist us to provide a personalised response to address your needs.

  • Please fill out the form below.
  • Once you have completed this form a staff member from Student Life Counselling Support team will contact you to discuss appointment options.
  • We aim to respond to your request within 1 business day (Monday to Friday).
  • Please indicate a phone number we can contact you on.
  • If you need assistance to complete the self referral form, please contact us by phone on 08 8313 5663 or by email from Monday to Friday, between 9.00am and 5.00pm.

We do not monitor this form after 4pm Monday to Friday. Forms submitted after 4pm will be responded to on the following business day. 

If you require urgent support after 4pm you can contact the University Crisis Line on 1300 167 654 / 0488 884 197.

Personal details
Recent significant trauma
Which issue(s) closely represents your current situation?
Modified Arrangements for Coursework Assessment (MACA)
Are you seeking support with an application for a replacement exam or extensions under the Modified Arrangements for Coursework Assessment (MACA) rules?
Please make sure you have read the MACA Rules and Counselling Support Guidelines
Practical information