Online Referral Form

Client Details

First Name Last Name Preferred Name Pronouns Date of Birth Mobile Number Email Address Residential Address Postal Address (if different)

Referral Details

Presenting Issues/Background Information: Required Service: Psychological Therapy Counselling Educational Assessment ASD Assessment Psychiatric Assessment (Medicare Item Code 291)
Does the individual have a current Mental Health Treatment Plan? (If yes, please provide a copy.) Yes No
Does the individual have NDIS funding? (If yes, please provide a copy of the Plan or alternatively, Plan Number, Plan Dates and Plan Goals.) Yes No
Please provide any other relevant information:

Referrer Details

Referrer Name Organisation Name Phone Number Email Address

Please attach any relevant documentation(s)

Choose File

Please note: If you provide client contact information (phone and/or email address), we will assume that you would like us to contact the client directly. Please leave these sections blank if that is not the action you would like us to take.

To discuss a referral, please call us on 1800 943 043.