Health professional client referral form

If you are a qualified health professional working with women living with breast or a gynaecological cancer in Victoria, you can refer them directly to Counterpart simply by filling out a few details.

Please complete the following form to arrange a Counterpart Peer Support Volunteer or staff member to contact your patient.

All information provided is transmitted and stored securely on the Counterpart database.

If you have any questions about your referral, please call on 1300 781 500 or email [email protected]