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Referrals
JCU Psychology Clinic Referral Form
JCU Psychology Clinic Referral Form
Client's Details
Client Full Name
DOB and Age
Cultural Background
Email
Phone
Next of Kin
(Name, relationship, contact number)
Occupation
(If applicable)
Concession
(Student / Health Care / Pension / Veterans Affair)
Reason For Referral
Service Type
*
This field is required
Individual therapy
Psychological assessment
MHTP (GP’s - please attach)
Attach File
Upload File
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)
Address
Email
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:
*
This field is required
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.
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