Referral Form

REFERRALS

Refer a Client to NM Psychology

NM Psychology accepts referrals for children, adolescents and adults seeking psychological therapy, assessment or funded support.

Referrals may be submitted by individuals, families, medical practitioners, allied health professionals, schools, support coordinators and other services.

Please provide relevant information to help us understand the client’s needs and determine the most appropriate next step.

Referrer Details

First Name

Middle Name

Last Name

Organisation

Position / Role

Phone Number

Email Address

Relationship to Client

Client Information

First Name

Middle Name

Last Name

Preferred Name

Date of Birth

Age

Gender

Pronouns

Address

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Suburb

Postcode

Phone Number

Email Address

Parent / Guardian Information

Parent/Guardian 1 Name

First Name

Middle Name

Last Name

Relationship to Client

Phone Number

Email Address

Parent/Guardian 2 Name

First Name

Middle Name

Last Name

Relationship to Client

Phone Number

Email Address

Who should NM Psychology contact regarding appointments?

Client Parent/Guardian 1 Parent/Guardian 2 Other

If Other, please specify:

Are there any court orders, parenting arrangements or decision-making considerations NM Psychology should be aware of?

Yes No

Please provide details

Parent / Guardian Information

Mental Health Care Plan

Yes No Pending

Referring GP

First Name

Last Name

NDIS Number

Plan Start Date

Plan End Date

Plan Manager

First Name

Last Name

Plan Manager Email

Support Coordinator

First Name

Last Name

Support Coordinator Contact

Claim Number

Case Manager

First Name

Last Name

Insurer

Insurer Phone

Insurer Email

Parent / Guardian Information

Other concern details

When did these concerns first begin?

Describe the main presenting concerns

Has the client received any prior assessment related to these concerns?

No Yes Not Sure

If yes, provide details of prior assessment

What are the main goals for support?

Current Supports

Please list providers if known

Risk and Safety Information

If Other, please specify

Additional information

Is there any immediate risk requiring urgent attention?

No Yes Unsure

Describe any immediate safety concerns

Is there a current safety plan in place?

No Yes Unsure

If Yes, please provide copy of Safety plan

Have emergency services been involved recently?

No Yes Unsure

If yes, provide details

Preferred contact person in an emergency

Risk and Safety Information

Referral Letter

Mental Health Care Plan or NDIS Plan

What Happens After a Referral Is Received?

1 Referral Review

NM Psychology will review the information and supporting documents provided.

2 Suitability Check

We will consider whether the requested service is suitable and whether further information is required.

3 Follow-Up Contact

The referrer, client, parent or guardian may be contacted to clarify the client’s needs, funding or appointment preferences.

4 Next Steps

Where the referral is suitable, the next steps may include intake forms, funding confirmation, an initial consultation or appointment scheduling.

URGENT SUPPORT

NM Psychology Is Not a Crisis Service

NM Psychology does not provide emergency or crisis support.

If you or someone else is in immediate danger, call 000.
For urgent mental health support, contact:

Lifeline: 13 11 14
Kids Helpline: 1800 55 1800
Suicide Call Back Service: 1300 659 467

Need Help With a Referral?

Contact NM Psychology to discuss service suitability, funding requirements or supporting documents before submitting the form.