Client Referral/ Booking Request Form

Client Referral/ Booking Request Form

Please fill out the following form in as much detail as you can. One (1) form for each participant is required.
Personal Details
Name of Participant*

Participant's First NameParticipant's Last Name
Preferred Name
D.O.B*

DayMonthYear
Date of Birth
Sex
The person’s biological and hormonal sex characteristics assigned at birth.
Gender Identity
Pronouns
Name of Parent/ carer if participant is under 18 years

First NameLast Name
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Address

Street Address

Street Address Line 2

CityState

Postal Code
Who does the child live with?
Requested Services

Play Therapy (3-12 years)Creative Counselling (10+ years)Holistic Youth Counselling (13+ years)Talk-based Counselling (teens and adults)Filial Family TherapyParent Support CounsellingNeurologic Music Therapy (NMT) ***please note; due to sound barriers in our current space, NMT services have temporarily been put on hold. A wait list for NMT services is open.
Appointment Communication Preference

PhoneEmailPhone/ Email
Preferred Session Times/ Availaibility (Please note: we are closed on Fridays)

Monday AMMonday PMTuesday AMTuesday PMWednesday AMWednesday PMThursday AMThursday PM
Medical History

Diagnosis, medications, allergies/ intolerances and past medical history.
Diagnosis
Please list any medications currently taking and their frequency
Please list any allergies/ intolerances and their description
Has there been a history of trauma, negative healthcare encounters or significantly stressful events?
Is there are family history of mental health, developmental delay or other relevant diagnosis'
Is there anything else you would like us to know about the client's medical history, development, or life experiences?
Support Services
What other support services is the client currently engaged with?
Funding Type
Funding Source
NDIS Details

NDIS details must be provided prior to your first session. If you are privately paying, please disregard this section and add N/A to any answers not relevant to you.
NDIS Number*
Plan Start Date

MonthDayYear
Date
Plan End Date

MonthDayYear
Date
**Please upload a copy of the participants current NDIS plan below, or email to kara@playcreative.com.au
Please add the participants current NDIS plan here

Cancelof
Fund Management
Plan-Management Name
Plan-Management Email for Invoices
example@example.com
NDIS Plan Nominee/ Representative

If other than the Parent/ legal Guardian
Plan Nominee Name

First NameLast Name
Plan Nominee Email
example@example.com
Plan Nominee Phone Number
Please enter a valid phone number.
Emergency Contact

The primary parent/ caregiver listed on this form will be the first point of contact. Please add an additional contact other than the primary parent/ caregiver in case of emergency.
Name

First NameLast Name
Relationship
Phone Number
Please enter a valid phone number.
Associated Contacts

These are associated with the participant to be included in different communications including a parent, support coordinator, or support workers etc that may be bringing the participant to therapy.
Please add permitted associated contact details below
Alerts

Information you add here will be displayed in important and confidential places.
Please add any medical alerts, DV order, Parenting Plan order details, or anything you would like to alert us about below
Referral Source
Who referred you?
Other
Do you have any current questions or concerns that you would like to share about the participants current circumstances?
Should be Empty:

Client Referral/ Booking Request Form

Personal Details

Medical History

Support Services

Funding Type

NDIS Details

NDIS Plan Nominee/ Representative

Emergency Contact

Associated Contacts

Alerts

Referral Source

Other