New Client Referral Form – COUNSELLING & THERAPEUTIC SUPPORT

Client Name *

First

Last

Client Age *

Client Email

Client Phone

Client Suburb

Parent / Guardian / Practitioner / Legal Representative

First

Last

Relationship to Client

Practice / Agency Name

Parent / Guardian / Practitioner / Legal Representative Email

Parent / Guardian / Practitioner / Legal Representative Phone

Contact Details *

Client
Parent / Guardian
Practitioner
Legal Representative

Who should we contact regarding this referral?

Contact Email *

Contact Phone *

Reason for Referral *

Does the client have any of the following (select all that apply): *

A current referral from a GP
A current Mental Health Treatment Plan
None of the above

Referring GP Name and Clinic

First

Last

Does the client have a current NDIS plan? *

If 'Yes', what is the Client's NDIS Plan Number?

If 'Yes', who manages the plan?

Self-managed
Plan Managed

If 'Plan Managed', what is the name of the Plan Management Organisation?

Other Relevant Information

Acknowledgement - By submitting this form you confirm that the Client consents to provide the details contained in this form to Linkare, and that the person selected in the 'Contact Details' consents to being contacted by a representative of Linkare in relation to this referral.