Therapy Referral

Therapy Referral - Adult

If you are a current NDIS participant, please use our NDIS Therapy Form below:

Please click ----> HERE

Personal Details

First Name *

Surname *

Preferred Name

Date of Birth *

Age *

Pronouns *

Gender *

Please describe *

Home Address *

Street Address *

City *

State *

Postcode *

Email Address

Mobile Telephone Number *

Do you identify as part of the gender and sexually diverse (often known as LGBTQIA+) community? *

Are you from an Aboriginal or Torres Strait Islander background? *

Are you from a culturally and/or linguistically diverse background? *

Are you employed?

Name of Employer

Your occupation

Referral Details

Who referred you? *

Please specify *

Referring medical practitioner's name

Referring medical practitioner's telephone number

Do you have a GP referral letter? *

Date of last contact with GP

Have you had any psychology sessions this year? *

How many sessions have you had? *

PLEASE NOTE:
You are eligible for 10 sessions per calendar year under a Mental Health Treatment Plan.

Name of previous/current counsellor/therapist

Name of counsellor/therapist's organisation

Date of last contact with counsellor/therapist

Preferences

Session preference *

Preferred method of contact to organise an initial consult *

Parent/Family/Support Name *

Parent/Family/Support Contact telephone number *

Please specify *

Service Request Information

Service Requested *

TherapyAssessment(s)

Purpose of Support

Summary of reason for referral and expected outcomes *

Supporting Information

Relevant diagnoses *

Experience (or witness) of personal trauma and/or abuse

Other Information

Is there anything else you would like the therapist to know? (i.e. specific communication or physical needs/preferences, employment, etc.)

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