External Referral Form

Are you a professional wanting to make a referral to our services? Use the form below to submit your information. Please note that we do not take on plan-managed clients, see our funding and fees page for more information about options we can accept.

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

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Referrer Name *

First

Last

Profession/Role & Organisation *

Phone

Email *

Client's Name *

First

Last

Date of birth *

Gender and preferred pronouns *

18) Please any

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

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)? *

Submit