Referral – self and for child – Susan Shaw Therapy

Referral Form

Referrals for yourself or your child

Complete the following online form to self-refer or to refer your child. Please provide as much information as possible, as this will assist with the referral process. There is also space to upload any relevant reports and NDIS plan.

Referrer Information

Refferer name

Relationship to client

Refferer phone

Refferer email

Is the client or their parent/guardian aware of and consent to the referral?

Yes No

Client Information

Client name

Date of birth

Phone

Address

Gender

Preferred pronouns

If under the age of 18 years or an adult under guardianship:

Are there any guardianship orders or additional care arrangements in place?

Yes No

Does the client have a specific diagnosis?

Yes No

Do you have concerns about the client’s current risk of harm to self or others?

Yes No

Reason for Accessing Therapy Support

Mental health issues

Emotional regulation issues

Behaviour issues

Negative view of self

Relationship and social issues

Trauma

Cognitive and executive functioning issues

Play skills / behaviours

Health and wellbeing

Gender or identity challenges

Other Information

Has the client previously seen a therapist or counsellor?

Yes No

Other relevant information (medication, treatment, social history etc.)

What are the goals for therapy?

What are the client's strengths?

Is the client an NDIS participant?

Yes No

NDIS number

NDIS plan dates

How is the NDIS plan managed?

Self-managed Plan managed

Please upload NDIS plan

Other services currently involved

Current school, kindy or childcare name (if relevant)

Year level

Contact person/teacher’s name:

Any learning or academic issues

Is there anything else that you think would be important for Susan Shaw Therapy to know to assist with this referral?

Please upload relevant reports (e.g. assessment and progress reports)

If you have any questions or need assistance to complete the form, please contact Susan Shaw Therapy on 0478 811 635 or susan@susanshawtherapy.au.

Once the referral has been submitted, a team member will be in contact to go through the referral.