Date of referral

Client details

Full name

Date of birth *

Gender *

Age *

What school does your child attend *

Full name of legal guardian *

Relationship to client *

Phone number *

Email address *

Address *

Reason for referral

What type of service are you looking for

Individual therapy (children)Individual therapy (adult)Family therapy Parent education

Any additional information *

Location of service required

In home Telehealth

Is this a medicare referral

YesNo

Do you have a Mental Health Care Plan

YesNo

Medicare number *

Reference *

Expiry date

Is the client a participant of the National Disability Insurance Scheme (NDIS)

YesNo

What funding source are they under

Plan managed Self-managedNDIA (if this is the case I will be unable to see you)

When is their plan start date?

When is plan end date?

What is their NDIS plan funding amount for psychology services

What are you funded for?

Behaviour Support Improving relationshipsImproving daily living skills (I can only supply services under this funding stream)

What are the psychology goals under the plan?

What supports are currently in place

Speech Pathology Occupational TherapyPhysiotherapy Other:

Your name (if not parent/ legal guardian above)

Phone number (if different to above)

Do you have consent from the person you are referring to share the information on this form *

Yes No

Person's preferred method of contact *

Phone callEmail SMS / text

Person's preferred contact time *

9 am - 11 am12 pm - 2 pm3:30 pm - 5 pm

Signature *

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