Hearth Therapy Studios

Hearth Therapy Studios - Referral

Please complete the form below to refer a client to HEARTH Therapy Studios. You will receive a response as soon as possible. All communication is treated as confidential. Submitting this referral does not commit you to any agreement. Once received, you will be invited to a complimentary, no-obligation 15-minute phone call to discuss your enquiry and next steps.
Referrer Information
Referrer
Full name of referrer*

First NameLast Name
Relationship to client/participant (if not self referring)
Organisation (If applicable))
Parent / Primary Caregiver Details. (Required if the client is under 18 and the referrer is not the parent or primary caregiver.)

First NameLast Name
YesNo
Contact Number
Please enter a valid phone number.
Email Address*
example@example.com
PhoneEmailEither
Referral Information

Client/participant details
Full Name*

First NameLast Name
DOB:*
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Funding
Funding Type
NDIS Details

(if applicable)
NDIS Participant number:
Plan ManagedSelf Managed
Plan Manager details (if planned managed):
Plan start/review date:
Referral Details
Reason for referral
This will be discussed in more detail in our initial contact call.
Are there any risks, safety considerations, or support needs we should be aware of prior to first contact?
This will be discussed in more detail in our initial contact call.
WednesdayThursdayFridayAny
MorningAfternoonEither
Crisis support

HEARTH Therapy Studios is not a crisis or emergency service. If you or your child needs immediate support, please contact Lifeline on 13 11 14, Beyond Blue on 1300 22 4636, Kids Helpline on 1800 55 1800, or 000 in an emergency. Aboriginal and Torres Strait Islander people can also contact 13YARN on 13 92 76 for culturally safe crisis support.

Thank you for your interest in HEARTH Therapy Studios. You will receive a reply to your referral within 2 working days.
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Hearth Therapy Studios - Referral

Referrer Information

Referral Information

Funding

NDIS Details

Referral Details