Intake/Referral Form

To book an appointment with a psychologist, please complete the Intake/Referral form below.

Once this has been submitted, we'll be in touch.

If you have any questions before then, please contact us at hello@theflourishproject.com or call us on 1300 406 460.

Today Date

How did you hear about The Flourish Project?

Client Details

First Name *

Last Name *

Preferred Name

Date of Birth *

Cultural Background

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

NoYes

Gender *

Pronouns

He/HimShe/HerThey/Them Other

If 'Other', please specify

Client Phone Number *

Client Email Address *A confirmation email will be sent to this email address once you have submitted this form.

Client's Address *

Street address *

City *

State *

Postcode *

Accessibility requirement(s) or interpreter requirement

Do you/the client have any disability, condition, or support needs we should be aware of?

Funding Type *

If 'Other' funding, please specify

Referrer Contact Details (if applicable)

If you are a referrer, please complete this section.

Referrer Name

Referrer Organisation

Referrer Email

Referrer Phone Number

Which service(s) are you seeking from a psychologist?

The Flourish Project offers the services listed below. Please select any services you would like support with. You may choose more than one.

Therapy and Assessments

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

To Access Medicare Benefits

Complete this section if you have been referred by a GP and plan to access psychology services using a Mental Health Care Plan (MHCP).
If you haven’t seen your GP for a MHCP yet, you can provide this information once you have it.

Referrer

Referrer Clinic

Please upload your Mental Health Care Plan (MHCP) here

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If available, otherwise you can provide this to us once available.

Medicare Number

Individual Identifier Number (IRN)This is the number found on your Medicare card before your name.

Medicare Card Expiry

Private Health Cover

If you will be claiming psychology sessions under your private health cover, we will provide you with a payment receipt to do so.

Private Health Fund

NDIS Plan Details

Participant NDIS Number *

Please specify the primary disability that qualified you/the client for NDIS eligibility:This helps us to provide appropriate and tailored care.

NDIS Plan Start Date *

NDIS End Start Date *

How is this support category managed? *

Plan ManagedNDIA ManagedSelf Managed

Name of Plan Manager (or if Self-Managed, the name of the person for invoices to be sent to) *

Email for invoices to be sent to Plan Manager or Self Manager *

Who will be signing the Service Agreement?

Please upload the current NDIS plan (if possible)

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ReturnToWorkSA Details

RTWSA Client Identification Number: *

Name of Client's RTWSA Case Manager *

Case Manager Email *

Case Manager Phone Number *

Email for invoices to be sent to RTWSA *

Medical History

Please list any diagnosed medical conditions you think we should be aware of:

Psychological History

Current mental health

Current diagnosed mental health disordersPlease list any mental health diagnoses you currently have (if known). This helps us tailor support to your needs.

What is your main reason for seeking treatment with a psychologist? *Please briefly describe what you'd like support with or what has led you here. For example, anxiety, mood, stress, trauma, relationship challenges, life changes/adjustment, emotional regulation, workplace difficulty or performance, personal growth, other concerns.

What are your expectations for therapy?

In the past six months, have you been hospitalised, or sought emergency/crisis support for your mental health?Any details you can share will help us provide safe and appropriate care.

Pervious mental health

Have you been diagnosed with any mental health conditions in the past?

Have you ever previously been hospitalised or sought emergency/crisis support for your mental health?Any details you can share will help us provide safe and appropriate care.

Goals and Collateral Information

What are the therapeutic goals? *What does the client want to achieve in sessions. This can include NDIS goals, we use these to tailor the therapeutic goals.

Please upload any relevant collateral information the psychologist should be aware of :

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For example, any relevant previous assessments or reports.

Anything else you'd like us to know?Feel free to share any preferences here too.

Home Visit Assessment

This home risk assessment is to be completed when it is requested that a psychologist attend the client's home to deliver services.

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/Behaviour Risk Assessment

This initial assessment will help the psychologist to understand and manage any existing 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? *

YesNoUnsure

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

If yes please provide details *

History of verbal aggression? *

YesNo

If yes please provide details *

History of suicidal tendencies? *

YesNo

If yes please provide details *

History of self-harm? *

YesNo

If yes please provide details *

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 *For clients under 18 years of age, your emergency contact must be a parent/guardian.

Relationship to Client *

Emergency Contact Phone Number *

Emergency Contact Email *

Primary Contact

Primary Contact Details

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

The client is the primary contact

Primary Contact Name

Primary Contact Phone Number

Primary Contact Email

Nominee / Guardian Details (if applicable)

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

If the client is under 16 years of age or unable to sign independently, a Nominee or Guardian authroised to act on their behalf will be required to sign consent forms. Please provide details below, if applicable.

Nominee/Representative/Guardian Name

Organisation

Contact No.

Additional Contact Information (if applicable)

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

If relevant, provide the details of any third-parties The Flourish Project may need to liaise with to provide holistic support or to coordinate services. This may include a GP,occupational therapist, speech pathologist, psychiatrist, support coordinator, accomodation support, support worker, etc. A Consent to Exchange Information Form will be arranged with the third-parties detailed.

Full Name

Relationship to Client

Phone

Disclaimer

By checking this box you acknowledge that The Flourish Project collects the above information to assist understand your needs and determine 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. *

Full name of the person who completed this form

This all we need for now, thank you.

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