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Welcome to RoSA’s web form which allows you to contact us securely through an encrypted process.

Please choose the referral tab relevant to you:

General Enquiries

Please complete the following fields for all enquiries.

Self Referral

If you are referring yourself to RoSA you can do so by securely providing your information below. One of RoSA's specialist counsellors will contact you via your preferred choice.

Can we leave a voicemail?
Can we send a text message?
Preferred way of contact:
Do you have a preferred contact time?

If you are a minor please provide the contact details of your parent or guardian below:

Refer Someone

If you are a GP; the police; a school; a statutory or voluntary organisation; a parent, family member or friend and would like to refer someone to RoSA, you can do so by securely providing your and your client's information below. One of RoSA’s specialist counsellors will contact the referred client.

The following information is about the person (Client) that you are referring to RoSA.

Has the person (Client) given their permission for the referral to RoSA and for RoSA to make direct contact with them?
Does your Client have preferred contact time?

If your Client is a minor please provide the contact details of their parent or guardian below:


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