MAKE A REFERRAL

How did you hear about Our Mindful Youth?

Which location are you referring to?

Referral Date

Services requested

Purpose of therapy

Who are you referring?

Name

Preferred pronouns

Birthday

Address

Who is this submitting this referral?

Name

Role in clients life

Phone

Details of NDIS Support Coordinator (if applicable)

Who is the best contact for this client

Name

Role in clients life

Phone

Address

Preferred day and time of contact

Medical details

GP name

Phone

Address

Please outline clients medical history / diagnoses:

Please outline clients mental health history / diagnoses:

Does the client have a history of trauma? YES / NO (experienced an event that was so frightening, horrible or traumatic that it still now, distresses you.) If yes, please outline history:

Does the client have a history of physical or verbal aggression towards others? YES / NO If yes, please outline history:

NDIS details (if relevant)
(please note, we can only invoice self and plan managed NDIS clients.)

NDIS details

NDIS number:

NDIS plan management: Self managed / Plan managed / NDIA managed

NDIS plan dates:

Invoicing details

Name of those responsible for paying invoices (if self or plan managed):

Agency name:

NDIS funded hours and / dollar amount from Improved Daily Living being allocated to Our Mindful Youth services (exact amount):

Why are you referring this client?

Referral reason and goals

Emotional trigger identification

Where do you require services?

Services location request

NDIS PLAN UPLOAD

Upload File

Upload supported file (Max 15MB - please compress if file exceeds this size or email through to details below).

* If you cannot upload your NDIS plan above, please email a copy of your plan to admin@ourmindfulyouth.com.au to reflect your NDIS goals, and show how the sessions will be funded.

** There may be circumstances where a client's support needs may exceed the capacity of Our Mindful Youth's services, and the skills of those employed by Our Mindful Youth. In these circumstances Our Mindful Youth will contact you as soon as possible to discuss your support options.

Following the July 2025 NDIS guidelines, appointments that require travel time that exceed thirty minutes (one hour of total travel time) from Armadale, Melbourne will be via Telehealth or a gap fee will be incurred.

Please advise your preference in the referral form below

Alternatively, you can fill in our referral form manually, and email it through to admin@ourmindfulyouth.com.au

MAKE A REFERRAL

Who are you referring?

Who is this submitting this referral?

Who is the best contact for this client

Medical details

NDIS details (if relevant) (please note, we can only invoice self and plan managed NDIS clients.)

NDIS details

Invoicing details

Why are you referring this client?

Emotional trigger identification

Where do you require services?

NDIS PLAN UPLOAD

Following the July 2025 NDIS guidelines, appointments that require travel time that exceed thirty minutes (one hour of total travel time) from Armadale, Melbourne will be via Telehealth or a gap fee will be incurred. Please advise your preference in the referral form below

​Alternatively, you can fill in our referral form manually, and email it through to admin@ourmindfulyouth.com.au​​

NDIS details (if relevant)
(please note, we can only invoice self and plan managed NDIS clients.)

Following the July 2025 NDIS guidelines, appointments that require travel time that exceed thirty minutes (one hour of total travel time) from Armadale, Melbourne will be via Telehealth or a gap fee will be incurred.

Please advise your preference in the referral form below

Alternatively, you can fill in our referral form manually, and email it through to admin@ourmindfulyouth.com.au