Intake/Referral Form

To register for our psychology services, please complete the Intake/Referral form below. 

Your referral will be placed on our waitlist and a member of our team will contact you as soon as we have capacity to take on a new client. 

If you have any questions, please contact us at or call us on 1300 406 460.  


Referrer Contact Details

Referrer Details (if applicable)

This is who we will discuss this referral with 

Participant/Client Information

Services Required

The Flourish Project provides the services listed below.  Please indicate the service(s) you require, you may select more than one.

Therapy and Assessments

The Flourish Project offers multidiciplinary Autism Spectrum Disorder (ASD) Assessments for adults. This is conducted by our team of a Clinical Psychologist and a Speech Pathologist in the one appointment.

The fee for an Autism Spectrum Disorder (ASD) Assessment completed by our Clinical Psychologist and Speech Pathologist is $2,145 (GST free).

Behaviour Support Services

Funding and Payments

(if applicable)
e.g. LSA Client ID, RTW Reference Claim Number (if applicable)
e.g. LSA Client ID, RTW Reference Claim Number (if applicable)

Background and Goals

Please include any behaviours of concern that require attention.
(e.g. Do you require a psychologist that can speak a certain language? Do you require a psychologist with certain expertise?)

Environmental (Home) Assessment

To be completed for services that are delivered at the Participant's home. This assessment looks at the environment in which the Flourish Project will be delivering services and includes the home and people who live there.



Can select multiple

Medical/Behavioural Risk Assessment

This initial assessment will assist the practitioner to understand and manage any safety concerns. It will aid the development of the Participant's Support Plan which will be discussed further during the initial meeting. 

Medical considerations
Behavioural considerations

Emergency Contact

Additional Contact Information

Would you like us to engage with any other person/organisation? 

Where relevant, provide the details of any third-parties The Flourish Project should coordinate supports with. These may include service coordinators, occupational therapists, speech therapists, psychiatrists, GPs, etc. Consent to Exchange Information will be arranged with the third-parties detailed. 

Primary Contact

Primary Contact Details

This is who we will contact directly to book appointments and who will receive automatic appointment reminders

(if applicable)

Nominee / Guardian Details

Authority to Act - Nominee/Representative/Guardian Details (if applicable)

If the participant is under 18 years of age or unable to sign independently, the Nominee or Guardian authroised to act on their behalf will be required to sign the Service Agreement / Consent forms. Please provide details below, if applicable. 

(if applicable)

Thank you, this is all we need for now.

Please let us know if you have any feedback or suggested improvements for our form.