Online PsychelpSydney Referral Form

Client Name: Date of Birth:
Address:
Phone: Fax: Email:
Type of Referral:        
Self   Yellow Pages    

GP/Doctor

    Solicitor     Insurer  

Name

  

Name

  

Name
Contact   Contact   Contact
Provider No.   Claim No.   Claim No.

Please indicate the service you require: Psychological Therapy/ Counselling

Self-Esteem/ Confidence   Anxiety/ Panic Depression
Loss or Grief   Eating Disorder/ Body Issues Relationship Issues
Avoidance/Commitment  Addictions/ Substance Control Stress
Cultural Adaptation  Communication Anger Management
Posttraumatic Stress  Sexual Abuse  Parenting Problems
If other, please specify:

Expert Opinion Assessments

Diagnostic Assessments:     
Psychiatric (DSMIV) Educational
Court Hearing:     
Family Court   Criminal Court Children's Court
Claim No.  
Workplace Motor Accident Victim of Violence
   
Workplace Rehabilitation Services: Claim No.  

Additional Details:

Do you have a Mental Health Medicare Referral from you Doctor:
Do you belong to a Private Health Fund:
Do you have an active compensation claim:

We would like you to answer a few preliminary questions:

Who referred you:    
How did you hear about PsychelpSydney    
Please indicate if you require Counselling or Assessment    

If you require counselling:

Have you had counseling before Yes or No    
How long ago: For How Long:

Is your referral about a:

  Personal Relationship Workplace Crisis or a problem effecting your  
  Emotional Health Mental Health Physical Health or Other Reason

Would you consider yourself at risk in some way Yes or No  

 eg Fear/Panic Depression Self-Harm Relationship Crisis Addiction
  Trauma Demestic Violence or Other Reason  

How urgently would you like an appointment: Within 24 hours    This week  Within 2 weeks

If you require an assessment :

Please indicate if there is a report requested by your:

Solicitor Doctor Employer Insurer concerning a injury Court proceeding in which you are involved
School College      

You will be asked for more detailed history at your first appointment but if you wish you may briefly add more information here:

Preliminary Consent Form:

Client name: I hereby give my consent to PsychelpSydney to arrange an appointment for the above services.
I understand that full confidentiality applies to counselling and therapy. For Expert Opinion/ Court Reports Limited Liability may apply when I have authorised a report to be sent.