Contact us.info@strengthpsychology.org0424 918 733224 South Valley Rd, Highton, VIC, 3216 Today's Date MM DD YYYY Client First Name * Client Surname * Date of Birth * Gender: * Person Completing Form * Parent/Carer School Representative Support Coordinator Community Organisation Representative (Mele/CP) Name of Person completing form: * First Name Last Name Name of Parent (External Referrers Only): If this referral is coming from an external organisation, please state the name of the parent of the young person being referred. First Name Last Name Parent contact email * Parent contact phone number * Suburb * How did you hear of us? * School Attending Previous Diagnoses: Does the person being referred have any previous diagnoses? Referral Concerns * Please describe the reasons you are seeking psychological support Has the person being referred experienced trauma? Yes - Complex (many events) Yes - Acute (single event) No Unsure or prefer not to say Please indicate support required: Counselling/Intervention Assessment/Testing Both Referral Type * Please indicate support required and how the sessions will be funded: Private Medicare Rebate (Mental Health Care Plan) NDIS Self-Managed NDIS Plan-Managed Cognitive Assessment (IQ Test) ADHD Assessment Vocational/Career Assessment Learning Disorder Assessment Autism Assessment Parent Support Sessions Parent Sessions For children being referred, it is often beneficial to do a small number of sessions with parents only. Is this something you'd be willing to participate in? Yes Maybe/Unsure No Not Applicable Consent for service - Please tick the option that applies to the person being referred: A detailed consent form will be provided at the time a referral is accepted. One parent can provide consent on behalf of a married or defacto couple. For separated or divorced parents, we will call you and discuss how consent is provided. Parents of the child referred are married or in a defacto relationship and both wish for the child to receive support The child's family arrangement is different to what is described above Not applicable - eg. Adult Self-Referral Does the referred person have a current care team? If so, who does it include? * Is the person being referred impacted by court orders? Yes - current or recent family court proceedings Yes - relating to an IVO or/and or custody Other Are you open to working with a provisional psychologist? Provisional psychologists are usually in the final stages of completing their Masters degree prior to attaining full registration. Yes Maybe No NDIS Number (If Applicable) Plan Manager (If applicable) What is your preference for session frequency? The majority of our clients attend fortnightly. This information helps us identify clinicians with the soonest availability. Weekly Fortnightly Monthly Anticipated number of sessions: Most people are seen for 6-10 sessions. More complex issues will commonly have longer treatment durations. How would you like us to contact you to discuss booking appointments? * Prefer to organise via email Prefer to organise over text Prefer to organise via phone Please provide information about your child's availability for sessions (days and times they are/are not available). Please note if you are happy for any day/time you may be able to be seen sooner. Thank you!
