Referral Form

Referral Form
Full Name of Client*

First NameMiddle NameLast Name
Date of Birth

MonthDayYear
Date
Full Name of Parent/Legal Guardian (if Client is below age 16 years)

First NameLast Name
Contact Number*
Please enter a valid phone number.Format: (000) 000-0000.
Email Address*
example@example.com
Address

Street Address and City

Street Address Line 2

CityState / Province

Postal / Zip Code
Reason for the referral*
Please offer as much detail as possible on the presenting concerns and how long these have been ongoing.

CONFIDENTIALITY
Information shared in therapy is confidential and managed in accordance with the Privacy Act 2020 and professional ethical standards. Confidentiality may be limited where there is serious risk of harm, child safety concerns, or where disclosure is required by law.

CONSENT
Consent is given for therapeutic services to be provided and may be withdrawn by you or the therapist at any time.

ATTENDANCE & CANCELLATIONS
A minimum of 24 hours’ notice is required to cancel or reschedule an appointment. Cancellations with less than 24 hours’ notice, or non-attendance, will be charged at the full session fee.

FEES & COMMUNICATION
The fees for the sessions will be discussed and confirmed with you during the initial phone call. Fees are payable on the day of the session unless otherwise agreed. All invoices for sessions will be emailed through to you for payment. Email and text communication are used for scheduling and administrative purposes only.

ACC / ORANGA TAMARIKI / SCHOOL REFERRALS
Where therapy is funded or referred by an agency, relevant information may be shared for coordination, reporting, or funding purposes, in line with informed consent and legal requirements.

TELEHEALTH CONSENT
Therapy may be provided via video or phone. Responsibility is accepted for attending sessions in a private and safe space. Telehealth may not be suitable during periods of high risk.

ACKNOWLEDGEMENT
Understanding and agreement to the above is confirmed below.

CAREGIVER CONSENT (for clients under 16)
Consent is provided by a parent or legal caregiver. Therapy is primarily for the child or young person. Information will not routinely be shared with caregivers unless consent is given, safety concerns arise, or disclosure is required by law.

Is the client below 16 years of age?
Yes No*
Signature
Should be Empty: