Joplin Clinic Online Referral Submission
Please call (02) 83191970 or email info@joplinclinic.com.au if you have difficulty using the form.
Who is seeking a psychologist?
Myself
My Child
My Partner
My Patient
Other
Have you obtained consent from the patient (referee) before submitting the referral to the Joplin Clinic's Online Triage Service?
*
Yes
No
Your Name
*
First Name
Last Name
Your Email
*
example@example.com
Your Phone Number
*
Your relationship with the person being referred:
Parent
Grandparent
Carer
Friend
Referer
Agency
Other
Patient's Full Name
*
First Name
Last Name
Patient's Date of Birth
-
Day
-
Month
Year
Date
Patient's Email
*
example@example.com
Patient's Phone Number
*
Please enter a valid phone number.
Patient's Gender
Male
Female
Non-Bindary
Prefer not to say
Other
Patient's Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Referrer Name
First Name
Last Name
Referral Date
-
Month
-
Day
Year
Date
What is your primary funding arrangement for services?
Medicare
Private Health Insurance
NDIS
Private (Self Funded)
Work Cover
WDO
Other
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Work and Development Order (WDO) Counselling Intake
If you have a current WDO or are seeking to reduce fines through eligible counselling activity, please complete the section below to help us support your application and participation.
Are you currently linked with a caseworker, lawyer, GP or other support worker?
Please enter your WDO number as issued by Revenue NSW
(You can find this in your WDO approval email or official documentation.)
What type of WDO activity are you seeking to complete with us?
Counselling / mental health treatment
Psychological assessment (for mental illness grounds)
Case management / support letter
Other (please describe)
If you selected 'Other'. Please describe the type of WDO activity you're interested in
Do you have a Centrelink reference number (CRN)?
How are your fines currently being managed?
In enforcement
Under a payment plan
Unsure
Other (please describe)
If you selected 'Other'. Please describe your current fines management arrangement
What is the total amount of fines you’re seeking to resolve through WDO support?
Which WDO eligibility category applies to you?
Please Select
Cognitive impairment
Serious addiction
Acute financial hardship
Homelessness
Other
Please upload a copy of your fines statement or enforcement order from Revenue NSW
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WDO Consent Statement
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Reason for Seeking Treatment
ADHD Coaching
Advocacy
Cognitive Issues
Addiction
Adjustment
Diagnostic Assessment
Ageing Concerns
Complex Trauma
Anger
Anxiety
Depression
Eating Disorders
Family
Financial Problems
Grief & Loss
Learning Difficulties
Loneliness
Obsessive Compulsive
Panic Attacks
Parenting
Post-Traumatic Stress Disorder
Relationship
Self-Harm
Sexual Issues
Sleeping
Stress
Suicidal Thoughts
Work Stress
Social Skills Training
Financial/Legal problems and or Fines
Other
Please specify any other information relevant to this referral
Please upload your referral or supporting documents (if applicable)
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How did you hear about us?
General Practitioner
Specialist
Family or friend
Social Media
Internet Search
WDO Sponsorship
Other
We'd love to get your support on our social chanels!
Submit
Submit
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