ONLINE REFERRAL FORM

ONLINE REFERRAL FORM

Lionhearted Counselling and Expressive Therapies
Name of Young Person*

First NameMiddle NameLast Name
Date of Birth*

DayMonthYear
Gender/Preferred Pronoun/s*

GenderPreferred Pronoun/s
Address*

Street Address

Street Address Line 2

CityState

Zip CodeCountry
Medicare Details*

Medicare NumberMedicare Expiry DateMedicare Reference Number
Does the young person have a current mental health care plan?*

YesNo
Is the young person and their parents/guardians aware and consenting to a referral to Lionhearted Counselling?*

YesNo
Contact Details of Parent/Guardian 1*

Name

Email

Phone NumberState

Zip Code
Contact Details of Parent/Guardian 2 - Optional

Name

Email

Phone NumberState

Zip Code
Has the young person received any previous diagnoses or are they currently on any medications? If so, please specify below:*
Is the young person currently engaging in self-harm?*

YesNo
Is the young person currently experiencing suicidal thoughts?*

YesNo
Please list any current or previous professionals involved with young person:*
What is the reason for the referral for the young person?*
Is the young person of Aboriginal or Torres Strait Islander background?

NoAboriginalTorres Strait IslanderBoth Aboriginal and Torres Strait Islander
Is the young person of a culturally and linguistically diverse background? If so, please provide some further details if relevant:
Referral Details (if applicable):

Referrer Name

Role at organisation/Job Title

Referrer OrganisationReferrer Contact Phone Number

Referrer Email Address
Is the young person allergic/hypersensitive or averse to sand?*

YesNo
Thank you. I will respond to your referral as soon as possible.
Should be Empty:

ONLINE REFERRAL FORM

Thank you. I will respond to your referral as soon as possible.