Referral form

New Client Referral Form

Counselling and Psychotherapy
Date*

DayMonthYear
Client Details
Is this referral for a child or adolescent?*
Please note if this referral is for a child or adolescent a separate consent form is required.
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Client Address*

Address

Indirizzo Riga 2

CityNazione / Provincia

Post Code
Home Phone Number*
Please enter a valid phone number.
Work Phone Number
Please enter a valid phone number.
Email*
example@example.com
Parent or Guardian Name (If Applicable)

First NameLast Name
Home Phone Number
Please enter a valid phone number.
Work Phone Number
Please enter a valid phone number.
Email
example@example.com
Relevant Medical and Mental Health History:*
Relevant Documents

School reports, patient health summary.
Cancelof
Reason for Referral
What is your reason for seeking therapy?*
Have your seen a counsellor or psychotherapist previously?*

YesNo
What type of appointment are you looking for*

In Clinic (Rutherford NSW)Video AppointmentPhone Appointment
Other Information
How did you hear about Haven Therapy?
Fee Structure
Haven Therapy Co is a private practice and as such no Medicare or private health insurance rebates are available. Fees are charged at $110 per 50 minute appointment. An invoice will be emailed at the time of your appointment, with payment required within 7 days, alternatively tap and go facilities are available for in clinic appointments. Do you understand and agree to these requirements?*

YesNo
Email address for invoicing:*
Consent
In order to provide quality assessment and therapeutic services, Haven Therapy Co will collect and record personal information relevant to your situation.

Purpose of collecting and holding information

Any personal information gathered as part of your assessment and treatment process will be kept securely and, in the interests of your privacy, used only by your therapist and the authorised personnel of the practice (as necessary). Your personal information is retained in order to document what happens during sessions, and to assist your therapist to provide a relevant and informed service tailored to you.

Access to client information

You are entitled to access your personal information kept on file, unless relevant legislation states otherwise. If you require access to your information please discuss this with your Consultant.

Disclosure of personal information

Personal information gathered by your therapist during the provision of services is considered confidential and will not be disclosed to another party except when:
- your prior approval has been obtained to:
  a) provide a written report to another professional or agency. eg. a Doctor or a Lawyer; or
  b) discuss your care with another person, eg. a Parent, Employer or Health Care Provider; or
- it is subpoenaed by a court; or
- failure to disclose the information would in the reasonable belief of your therapist or another person at serious risk of harm; or
- disclosure is otherwise required by law.
I, Name* have read and understood this consent form, and i agree to the above conditions to the services provided by Haven Therapy co.
Signature*

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New Client Referral Form

Client Details

Reason for Referral

Fee Structure

Consent