Referrals

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Referrals

Make an Appointment or Referral

Make a Referral / Make an Enquiry

Name: *

Organization: *

Contact Number: *

Email: *

Is Your Enquiry/Referral for:

Corporate Services
Leadership & Strategy

Comments/Referral Details: *

I Wish To Make an Early Intervention

Your Name: *

Contact Number: *

Email: *

Brief Background Regarding Referral: *

Worker's Details

Employee's Name: *

Position/Title:

Contact Number:

Reasons for Referral:

Initial Assessment
Workplace Assessment
Counselling Assessment
Stress Management
Mediation Between Employee and Manager

Organizational Health Screening
Return to Work Case Management
Pain Management
Anger Management
Critical Incident Debriefing
Other

If other, please describe:

Brief Background of Issues:

Local Area Contact/Manager

Employer Name:

Position/Title:

Work Phone:

Email Address:

Services Required

Talk with Referrer/Employer Contact
Meet and Assess Work Group
Provide a Written Report to Employer Contact
Provide Treatment(Enter approved sessions here)
Critical Incident Debriefing
Other

If other, please describe:

Number of Sessions:

How Did You Hear About PsyCare's Services? *

I Wish to Make an Appointment

Name: *

Contact Number: *

Email: *

Which office location would you prefer to be seen at?

Coorparoo
Mermaid Beach
Mt Gravatt
Morayfield
Nundah

Scarborough
Spring Hill
Sunny Bank
Tweed Heads
Warner

Would you prefer a male or female psychologist?

Male
Female
No Preference

Comments/Reason for Referral (optional):

Do you have a GP Mental Health Care Plan? *

Yes
No

Do you have private health insurance? *

Yes
No

Are you an existing or previous client? *

Yes
No

How Did You Hear About PsyCare? *

I Wish to Refer a Client

Client Name: *

Contact Number: *

Email: *

Which office location would be most convenient for your patient?

Coorparoo
Mermaid Beach
Mt Gravatt
Morayfield
Nundah

Scarborough
Spring Hill
Sunny Bank
Tweed Heads
Warner

Please choose your preferred psychologist:

If none, would you prefer your patient to see a male or female psychologist?

Male
Female
No Preference

GP/Mental Health Care Plan Referred?

Yes
No

Date of completed plan

Are you an existing or previous client?

Yes
No

Primary Diagnosis under Mental Health Plan:

Acute Psychotic Disorder
Adjustment Disorder
Alcohol Use Disorders
Bereavement Disorder
Chronic Psychotic Disorder
Conduct Disorder
Depression
Dissociative Disorder
Drug Use Disorder
Eating Disorder

Generalised Anxiety Disorder
ADHD/ADD
Mixed Anxiety and Depression
OCD
Panic Disorder
Phobic Disorder
PTSD
Sleep Problems
Unexplained Somatic Conditions
Other

If other, please describe:

Relevant Medications/Information:

Focused Psychological Strategies(multiple strategies allowed)

Psychoeducation
Cognitive Behavioural Therapy
Relaxation Strategies

Skills Training
Interpersonal Psychotherapy
Other

If other, please describe:

Referring GP Name:

Provider Number:

Referring GP Contact Number: *

Referring GP Email Address: *

How Did You Hear About PsyCare? *

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