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 hello@theflourishproject.com or call us on 1300 406 460.

Disclaimer

By checking this box you acknowledge that The Flourish Project collects the following information to assist in determing if we are able to provide the with services enquired about. More details on how we store and what we do with your information can be found in our Privacy Policy on our website. *

Referrer Contact Details

Referrer Details (if applicable)

This is who we will discuss this referral with

Referral Date

How did you hear about The Flourish Project?

Referrer Name

Referrer Organisation

Referrer Email

Referrer Phone Number

Participant/Client Information

First Name *

Last Name *

Date of Birth *

Does the client identify as Aboriginal and/or Torres Strait Islander *

NoYes

Gender *

Pronouns *

He/HimShe/HerThey/ThemOther

If 'Other', please specify

Client Phone Number

Client's Email Address

Client's Address *

Street address *

City *

State *

Postcode *

Accessibility requirement(s)

Interpreter Requirements

Yes

Do you/the client have a disability we should be aware of?

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

Specialist Behaviour Support Intervention and Behaviour Management Plan

Will we need to visit the client at home?

YesNo - I/the client can come to the clinic

Funding and Payments

Are you an NDIS participant? *

YesNo

Participant NDIS Number *

NDIS Plan Start Date *

NDIS End Start Date *

How will services be funded? *

How is this support category managed? *

Self ManagedPlan ManagedNDIA Managed

How is this support category managed? *

Self ManagedPlan ManagedNDIA Managed

Name of Plan Manager or if Self Managed name of person invoices will be sent to *

Please provide email of Plan Manager or if Self Managed email invoices will be sent to *

Medicare Number *

Individual Identifier Number *

Expiry Number *

Please upload your MHCP plan here

Browse

(if applicable)

Organisation's Participant Numbere.g. LSA Client ID, RTW Reference Claim Number (if applicable)

Name of Plan Manager or if Self Managed name of person invoices will be sent to *

Please provide email of Plan Manager or if Self Managed email invoices will be sent to *

Organisation's Participant Numbere.g. LSA Client ID, RTW Reference Claim Number (if applicable)

Background and Goals

What are your/the client's goals related to the service/s being requested? *Please include any behaviours of concern that require attention.

Are there any restrictive practices currently in use?

YesNoUnsure

Please upload NDIS plan here (or at minimum Participant goals and funding details for services requested)

Browse

Please upload any relevant information our practitioners should be aware of (i.e. previous assessments, medical history, legal documents)

Browse

Any other information you would like to tell us?(e.g. Why you are seeking support, whether 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.

Access

Type of premises *

Unit/FlatHouseSupported Residential Facility/SIL

Bushfire Risk Zone *

YesNo

Remote Location *

YesNo

Mobile/Phone Reception *

YesNo

Street Visibility *

YesNo

Available Street Parking *

YesNo

Entry Door *

FrontSideRear

2 or more exits? *

YesNo

Occupants

Are there pets? *

YesNo

If yes, please provide details *

Is there known substance abuse? *

YesNo

If yes, please provide details *

Is anyone at the premises prone to violence? *

YesNo

If yes please provide details *

Any known weapons or firearms? *

YesNo

If yes please provide details *

Will there be smoking around our practitioner? *

YesNo

Is the client willing to not smoke at appointments? *

Are there any safety considerations the practitioners should be aware of/consider when providing services?

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

Seizures? *

YesNo

Allergies? *

YesNoUnsure

If yes, please provide details *

Are there any other medical conditions the practitioners should be aware of (including any Medical Emergency Response Plan)?

Behavioural considerations

History of physical aggression or violence? *

YesNo

History of verbal aggression? *

YesNo

History of suicidal tendencies? *

YesNo

History of self-harm? *

YesNo

In the last 12 months has there been any behavioural incident(s)? If so, please detail. *

Are there any other safety considerations the practitioners should be aware of?

Emergency Contact

Emergency Contact Name *

Relationship to Participant *

Emergency Contact Phone Number *

Emergency Contact Email

Additional Contact Information (if applicable)

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.

Name

Relationship to Participant

Phone

Primary Contact

Primary Contact Details

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

Primary Contact Name *

Primary Contact Email *

Primary Contact Phone Number *

Organisation(if applicable)

Nominee / Guardian Details (if applicable)

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.

Nominee/Representative/Guardian Name

Organisation(if applicable)

Contact No.

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