SECTION A: About the person receiving services

Name

First Name

Last Name

Chosen / Preferred Name:

Pronouns

She/Her

He/Him

They/Them

Prefer not to say

Not listed (please provide details)

Home Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

Emergency Contact Name

Relation to client

Emergency Contact Number

Referring Doctor Name & Provider Number

How did you hear about us?

Referred by GP / Health Practitioner

Referred by family or friend

Social media

Internet / Website

Other

SECTION B: Financial Information

Who is responsible for payment?

Please provide name and contact details

Is your appointment covered by any of the following?

NDIS

Work Cover

TAC

Other

Private Health Insurance Provider & Number (if applicable)

SECTION C: Medical Information

Current Diagnosis (incl. mental health conditions)

Medical Conditions

Current Medications

SECTION D: Presenting Concerns

What is the reason for your appointment?

What are you hoping to achieve with the assessment?

SECTION E: Agreement

To the best of my knowledge the above information is correct and should my information change, I will inform SAL Consulting. I agree to attend appointments on time and make every effort to cancel within 24hrs if I am unable to attend / need to reschedule. Pay on the Day Policy Payment of consultation fees is expected at the time of your appointment. If you havePrivate Health Insurance, please note that full payment is expected at the time of yourappointment. It is then your responsibility to claim back any applicable rebates. If payment will be made through a third party contract (NDIS etc). You will not be required to pay onthe day of your appointment. Cancellations We understand circumstances may cause you to cancel an appointment / booking. Pleasecontact us if you need to reschedule or cancel your appointment. If less than 24 hoursnotice is given or you have not notifi ed us at all, you may be charged up to 100% of theoverall consultation fee.

I agree to the above conditions

Yes

SECTION F: Consent

I, (or your person responsible / guardian) have permitted the SAL Consulting Psychologist /Provisional Psychologist to provide psychological assessment services.

I do consent to the above

Yes

Agree and sign

The person giving consent must write their full name here.

Referral Form
Psychology Assessment

Acknowledgment of Country

Deceased Persons

Follow Us

1300 851 795

Referral FormPsychology Assessment

Acknowledgment of Country

Deceased Persons

Follow Us

1300 851 795

Referral Form
Psychology Assessment