Date of referral

Client Details

Name *

Date of Birth *

Address *Include any specifics re parking or access

Email address *

Phone Number *

Referral Information

What type of referral is this? *

Mental Health Treatment Plan/Better Access InitiativeSelf ReferralDVA ReferralNDIS (Self managed or Plan managed client) Other

Please complete this section if you are submitting this form on behalf of another person.

Name

Phone

Relationship to client above

Organisation

Is the referrer willing to be contacted regarding this referral if required?

YesNo - Please contact the client only

Reason for Referral

What is your primary reasons for seeking psychological services? *

Are you willing to actively participate in psychological services? *

YesNo

Have you experienced any of the following?

AnxietyDepressionTrauma/PTSD Stress/BurnoutEmotional Regulation issuesBehavioural concernsRelationship DifficultiesAdjustment IssuesGrief/LossNeurodevelopmental concerns (ADHD/Autism)Symptoms of PsychosisSuicidalityOther mental health conditions

Any additional details you wish to add.

Type text below

If you wish to attach any supporting documents please upload here.

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Additional documents

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Informed Consent

Client consent *

The client consents to this referral and agrees to be contacted by Empower Healing to arrange an appointment.I have obtained the clients consent to submit this referral. I have informed them that Empower Healing will contact them about appointment scheduling.

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