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JCU Psychology Clinic Referral Form

JCU Psychology Clinic Referral Form

Client's Details

Client Full Name

Gender

DOB

Cultural Background

Phone

Address

Next of Kin (Name, relationship, contact number)

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

Reason For Referral

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?

Referrer Details

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

Name & Title

Organisation (if applicable)

Referrer Address

Referrer Email

Referrer Phone

Disclaimer

As the client, parent/guardian of client or referrer to the client, please read and acknowledge the following disclaimers to ensure you can be added to our waitlist in a timely manner. If you are unable to check off one or more of the following, you will need to find alternative referral pathways which we are happy to assist you with.

I / we understand that: *

The JCU Psychology Clinic is a training clinic for provisional psychologists undertaking post-graduate training, who are supervised by fully registered clinical psychologists.

The JCU Psychology Clinic does not accept referrals that are likely to need more intensive support. The JCU Psychology Clinic do not provide services for the following issues: Walk-in, crisis, or emergency services | Medico/legal, worker’s compensation, family court, or other legal matters | Criminal-related behaviours or concerns | High risk of suicidality or self-harm | High risk of violence to self or others | Current psychotic behaviours

I understand that the JCU Psychology Clinic is a training clinic and as such, provisional psychologists are available to provide services for varying amounts of time. Should my situation mean that I require further sessions beyond the time my clinician is able to provide those services, I will be handed over to a new clinician. I therefore understand that I cannot expect to stay with a particular clinician for any specified period of time.