External Referral Form

Are you a professional wanting to make a referral to our services? Use the form below to submit your information.

If you are a client looking to self-refer, please use our new client enquiry form.

Please enable JavaScript in your browser to complete this form.

Referrer Name *

First

Last

Profession/Role & Organisation *

Phone

Email *

Client's Name *

First

Last

Date of birth *

Gender and preferred pronouns *

Parent/Guardian name/s (if client is under 18)

Client's phone number *

Client's email address *

Client's home address *

Preferred method of contact *

Phone
Email
SMS

Reason for referral *

Assessment
Ongoing therapy
Unsure
Other

Assessment referral

Autism
ADHD
Cognitive assessment
Learning/educational assessment
Unsure
Other

interpreter preferred pronouns

Please provide a brief description of any relevant background information, concerns, and presenting issues. *

Are there any court orders in place that apply to the client? *

Is there any risk involved for the client, such as unsafe home environment, Child Protection involvement, self-harm, or suicidal ideation? *

Please note Minds of All Kinds Psychology is not a crisis service and if there is immediate risk of harm, please contact appropriate medical practitioners or crisis lines: Triple Zero Lifeline: 13 11 14 Kids Helpline: 1800 55 1800

Are there any cultural or language considerations (e.g., interpreter needed)? *