JCU Health Psychology Referral Form

PLEASE NOTE, that there is currently no wait for Therapy services and approximately 6 months for assessments from the date of referral.

Client's Full Name

Gender

DOB

Cultural Background

Phone

Address

Next of Kin (Name, relationship, contact number)

Concession (Student / Health Care / Pension / Veterans Affair)

Service Type *

Individual therapy

Psychological assessment

MHTP (GP’s - please attach)

Reason for Referral (Please provide information about your key concerns)

Are you seeing anyone else about this issue?

(e.g., GP, other medical / allied health professional, education professional)

Name & Title

Organisation (if applicable)

Referrer Address

Referrer Email

Referrer Phone