Referral Form Referrer Details * First Name Last Name Role/Relationship to Client * GP Support Coordinator Parent/Carer Allied Health Professional Self Organisation (if applicable) Phone * (###) ### #### Email * Client Details * First Name Last Name Client Date of Birth * MM DD YYYY Client Gender / Pronouns * Client Address Client Phone * (###) ### #### Client Email * Is the Client Under 18? * Yes No Parent/Guardian contact details (If Under 18) Type of Support Required Counselling Assessment Parenting Support Help with Complex Behaviour Other (please specify) Problem or Harmful Sexual Behaviour Therapeutic Assessment & Counselling Supervision Secondary Consultation Brief Description of Concerns / Support Sought Referral Type / Funding Source * NDIS Medicare – Mental Health Treatment Plan TAC Private Health Insurance (Doctors Health, St Lukes, HCF, BUPA, Teachers Health Fund) NDIS Number (If NDIS selected) Plan Start Date (If applicable) Plan End Date (If applicable) NDIS Plan Management Type Self-Managed Plan-Managed Medicare Card Number (If referred by GP MHTP) Reference Number (next to name) Expiry Date MM DD YYYY Has a GP Mental Health Treatment Plan been completed? Yes No Name of GP Who Completed MHTP GP Clinic Name & Location Any Additional Information You’d Like to Provide? Privacy and Consent Statement * By submitting this form, you confirm that you have obtained the client's informed consent (or guardian consent if under 18) to share this information with Hayley Fisher (Understanding You Counselling) for intake and therapeutic purposes. I understand that all information will be kept secure confidential and managed in line with Australian Privacy Principles. I confirm I have obtained the necessary consent to submit this referral form. Thank you — your referral has been received. Hayley will review the information and be in touch within 2–3 business days. If the matter is urgent or you need to follow up, please contact: info@understandingyoucounselling.com
