For professionals

Referral Form

For GPs, paediatricians, schools and allied health colleagues. Amy will confirm receipt and let you know whether she can take the referral.

Referrer details

Referrer name

Profession

Organisation / practice

Phone

Date of referral

Address

Client details

Full name

Date of birth

Preferred name

Pronouns

Phone

Address

Parent/guardian details (if under 18)

Emergency contact

Is the client under 18 years of age?

Choosing yes adds the additional questions required for young people.

NoYes

Referral information

Reason for referral

Presenting concerns

Goals for therapy

Duration of concerns

Mental health treatment plan date (if applicable)

Previous interventions attempted

What would a successful outcome look like?

Relevant medical and mental health history

Relevant medical history

Include anything that may impact treatment.

Current diagnosis(es)

Including provisional diagnoses if applicable.

Previous psychiatric admissions

Including discharge summary where available.

Medications

One per line — medication, dose, frequency, reason.

Risk assessment

Please complete every line. If any risk is identified, give details below so the referral can be triaged safely.

Suicide risk

Self-harm

Aggression

Family violence

Child protection concerns

Substance use

Please provide details if any risks are identified

Funding

Medicare sessions used this calendar year (out of 10)

Current supports

Names and contact details of other services involved

School and education

These questions apply to clients under 18 years only.

School name

Year level

School wellbeing contact (if involved)

Attendance concerns?

NoYes

Alternative education / home schooling (if applicable)

Living arrangements

Who does the young person live with?

Parenting arrangements

Shared care, sole care, foster care, kinship care, etc.

Other relevant information

Anything else that may assist with treatment

Family circumstances, cultural considerations, communication needs, or anything else.

Sending supporting documents

Files cannot be attached to this form. Once you send it you will receive a confirmation email — reply to that with the Mental Health Treatment Plan, psychiatric reports or assessment reports attached, or send them to hello@emberandoaktherapy.com.au.

Consent

I have obtained the client's (or parent/guardian's) consent to share this information for the purpose of referral to Ember & Oak Therapy.

Type your full name to sign

Your answers are emailed straight to Amy Inglis and are not stored on this website. Email is convenient but never completely secure — if you would rather not send something in writing, leave it blank and raise it in session instead. How your information is handled is set out in the privacy policy.

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