Located In
Request Appointment

Psychology Referral Form

My Psychology Tasmania welcomes referrals from people within the community wanting to refer themselves to our service or from other professionals wanting to refer people to our service.

Important to Note: We do not accept referrals for high-risk clients or actively psychotic clients. We also do not provide crisis or emergency support. Please contact our practice to confirm suitability for meeting your needs. My Psychology Tasmania reserves the right to refuse any referral.

    Service Request

    Service Type: Please indicate if you are seeking therapy or assessment services

    Referrer Details

    Client Details

    Do you identify as a Aboriginal/Torres Strait Islander?

    Emergency Contact (if applicable)

    Has the client been to this practice before?

    Reason For Referral

    Location Request (The service provider will advise if community or telehealth is possible)

    Funding Type

    NDIS

    How is plan managed?

    Participation Number

    Plan Manager (if applicable)

    Person/s Responsible for Billing

    Plan Start Date

    Plan End Date

    Available Funds/Hours for Each Service Referred

    Home Care Package (HCP)

    Home Care Package Information

    Community Home Support Plan (CHSP)

    Community Home Support Plan Information

    Home and Community Care (HACC)

    Home and Community Care Information

    Private Health Fund

    Fund Name

    Fund Number

    Expiry Date

    Other Funding

    Fund Information

    Medicare

    Card Number

    Individual Reference Number (IRN)

    Expiry Date

    Type Of Referral

    Dept Veteran Affairs Card

    Card Number

    Expiry Date

    Client Consent

    The Referrer confirms the Client has agreed to this referral being made on their behalf

    Support and Emergency Contacts

    © 2022 MyPsychology Tasmania | ABN: 91 428 242 665 | Privacy Policy