Referral Form for EVAWG - Zachary Geddis Trust

How we can help you

Getting in touch and obtaining support from ZGBTST is simple – with same day response you can assure your needs are in safe hands with us.

Disclaimer:

If you are worried about the safety of a loved one, it is important that you seek assistance immediately.
ZGBTST works in collaboration with local statutory services to complement their care.
ZGBTST does not provide medication or access to psychological services, and we are unable to do immediate call outs.
If you would like guidance on how to achieve the right support for someone you feel may be at risk, please use our contact form to get in touch.

Your Name

(if under 18, name of Parent)

Phone Number

Date of Birth

Email Address

How do you prefer to be contacted?

What's your address?

Please provide the details of your Doctor:

Please detail any other organisations you are receiving support from

Can you briefly describe your Mental Health background?

Are you on any Medication at the moment?

What is your availability for sessions?

Any message you would like to add: