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

* 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. Those accessing Our Mindful Youth services through their NDIS supports have the choice of the service provider delivering their skill building supports. In some circumstances (such as not meeting client needs) Our Mindful Youth may not be the most ideal service provider. If the range/type of services provided by Our Mindful Youth do not best meet the needs of a participant, Our Mindful Youth encourages clients to source more suitable services.

Connect with us on Instagram!

About referrals:

All referrals are managed by our admin staff. They will gain an understanding of any difficulties and goals for therapy, and make an initial appointment with the most appropriate clinician, also providing you with our Welcome Paperwork and Service Agreements. If clinicians are at full capacity at the time of your referral, you will be placed on a waiting list. You will be contacted as soon as possible following the submission of your referral.

** Please note, should you have any difficulty filling out the online form, please ensure you have answered all questions with an asterisk beside them. This form can not be submitted without these filled in.

Alternatively, you can print and fill in our referral form manually, and email it through to admin@ourmindfulyouth.com.au. This is found above as a PDF file.

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

Connect with us on Instagram!

About referrals:

** Please note, should you have any difficulty filling out the online form, please ensure you have answered all questions with an asterisk beside them. This form can not be submitted without these filled in.

Alternatively, you can print and fill in our referral form manually, and email it through to admin@ourmindfulyouth.com.au. This is found above as a PDF file.

129A Chapel Street, Windsor 3181

374 Pakington Street, Newtown 3220

@ourmindfulyouth

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

Connect with us on Instagram!

About referrals:

​

** Please note, should you have any difficulty filling out the online form, please ensure you have answered all questions with an asterisk beside them. This form can not be submitted without these filled in.

​

Alternatively, you can print and fill in our referral form manually, and email it through to admin@ourmindfulyouth.com.au. This is found above as a PDF file.

​

​

129A Chapel Street, Windsor 3181

374 Pakington Street, Newtown 3220

@ourmindfulyouth

​

​

​

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