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External Referral Form

Submitting Your Referral Form

Thank you for choosing Oracle Psychology. All Third-Party External Referrers (e.g., referrals from schools, NGO's, DCJ, NSW Health, etc.) will need to complete this form. After the form has been completed, admin will follow up for processing.

For any further queries, please consult our detailed website (www.oraclepsychology.com.au), including information regarding fees, clinicians and services.

A Psychologist Talking to A Little Girl — Oracle Psychology Child & Adolescent Psychologists Newcastle in Newcastle, NSW

Client Information

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* Indicates required field

Today's Date *

Referring Agency *

Agency Address *

Referring Professional *

Referrer Phone Number *

Referrer Email Address *

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Client's Legal Name *

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Client's Preferred Name

Client's Age *

Assessment Type *

If Other Assessment Type (Please Specify)

Primary Therapy Concern *

If Other Therapy (Please Specify)

Behaviour Support Requirements *

Are there restrictive practices in place or needed?

Restrictive Practices Details (If Applicable)

The Appointments Will Be Attended for The Purpose Of *

NDIS Participant Id (If Applicable)

NDIS Plan End Date (If Applicable)

NDIS Plan Type (If Applicable) *

NDIS Funding Type (If Applicable) *

NDIS Plan Manager Organisation and Contact Details (If Applicable)

Additional Information Regarding Billing

The Report Should Be Sent to *

Who to Contact for Appointment Scheduling/Rescheduling *

Client's Date of Birth *

Client's Gender (Other)

Postal Address *

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Client's Gender *

Client's Email *

Client's Primary Mobile Number *

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Who Does the Client Live with (If the Client Is a Child)

Living/Custody Arrangements (If Applicable)

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If the client is a child and their parents are separated please answer the following:

Are both parents aware of the psychological consultation?

Do both parents consent to psychological consultation?

Additional Comments Regarding Consent (If Applicable)

Are Court Orders in Place?

Court Orders (If Applicable)

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For all clients please enter any additional comments or information if required:

Reason for Referral/Main Concerns *

Diagnoses (if any)

List Previous Assessments in the Past Year (If Any)

Any hospitalisations relating to the clients mental health?

Risk to self or others?

Comment

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Consent Form

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PLEASE READ ALL OF THIS INFORMATION CAREFULLY AND NOTIFY RECEPTION IF YOU ARE UNSURE OF ANYTHING

Please note that by completing this form you are opting to be entered onto our waitlist for services with Oracle Psychology. If your concerns are high risk or urgent, please call the Government Mental Health Line on 1800 011 511 for further assistance. Additional details about this service are also available here. If you are experiencing an emergency or need immediate help, please call 000.

By completing this form, you understand that we are not guaranteeing that Oracle Psychology can provide psychological services. You also understand and agree that we are not accepting any duty of care for service provision at this point in time. However, we will endeavour to contact you to offer appointments for our ongoing therapy services if/when they become available in our schedule.

Please Note: If, after reading this page, you are at all unsure of what is written, please discuss it with the Reception Staff.

Acknowledgement and Agreement to Proceed

"I have read and understood the above Consent Form. I agree to these conditions for the psychological services provided by Oracle Psychology."

Name of Person Providing Consent *

Agreement *

I have read, understood and agree with the above Consent Form