Submit a Referral

Please Note:

This is a new referral form, if you are experiencing any issues with this form please submit a contact request form located at the bottom of every page on our website. Your feedback is greatly appreciated.

Therapeutic Support Referral Form

Personal Details:

Participant preferrence of pronouns?

Participant First Name

Participant Last Name

DOB:

Address

Participant Phone

Participant Email

Would you like to share more details about your cultural heritage or any cultural preferences that might be relevant to the support coordination services you're seeking? This information is entirely optional, and your privacy will be respected.

Would you like to share more about your LGBTQIA+ identity to help us better understand and support your needs? This information is entirely optional, and your privacy will be respected.

How can we make sure your service is culturally safe or inclusive for you?

What is your preferred language?

Primary Support Person:

First Name

Last Name

Phone

Referrer Details:

First Name

Last Name

Phone

Decision Making:

First Name

Last Name

Organisation/relationship to you

Phone

Medical and Mental Health Information:

Existing Health Information: Please list any physical health issues that you consider relevant to our working together

Mental Health Information: Please list any diagnosed mental health conditions

Do you consider these diagnosed health conditions to be accurate?

First Name & Clinic Name

Phone

Engaging in Therapy:

Have you previously consuled with:

a counsellor

a psychotherapist

a psychologist

a psychiatrist

What was helpful or unhelpful during those consultations:

Please describe:

What are your hopes or goals for counselling?

What do I need to know about how you to best support you?

Payment Information:

Agreed Rate Per Hour:

How many sessions (if known):

Email Address for Invoices:

NDIS Specifics:

NDIS Number

Plan Start Date:

Plan End Date:

What service(s) are you seeking?

Individual Therapy - 15_056_0128_1_3 - Assessment Recommendation Therapy or Training - Other Professional - Improved Daily Living - $193.99

Counselling & Psychotherapy - 15_043_0128_1_3 - Assessment Recommendation Therapy or Training - Counsellor - Improved Daily Living - $156.16

Total funding amount available:

Self-Manager Name (LAC):

Self-Manager Phone

Self-Manager Email

Plan Manager Name (LAC):

Plan Manager Phone

Plan Manager Email

NDIS Planner/Local Area Coordinator Name (LAC):

NDIS Planner/LAC Phone

NDIS Planner/LAC Email

How does a participant endorse a provider? Participants endorse providers by calling the NDIS on 1800 800 110 and letting them know they want to endorse a provider in the PACE portal. They will need to give the name and NDIS Provider Number of the company they wish to endorse.

Marketing & Service Delivery Feedback:

How can we ensure our service meets your needs?

Please specify 'Other'.