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NDIS Referral Form

We welcome NDIS referrals for participants seeking compassionate, professional psychological care. Submit the referral form below and our team will be in touch to discuss next steps.

"*" indicates required fields

Client Details

Client Name*

First Last

Date of Birth*

DD slash MM slash YYYY

I Identify As*

Phone*

Email*

Address*

Street Address City/Town State Postcode Country

If the client is a child, what school do they attend?

Year Level

Teacher Name and Contact Details

NDIS Plan Number*

Current Plan Dates (Start and End)*

Who Is Completing This Form Today?*

Client

Support Coordinator

Parent/Legal Guardian of Client

Other

Name*

If Other is Selected, Please Detail

Relationship to Client*

If Other is Selected, Please Detail

Has the client given you permission to make this referral?*

Yes

No

This referral can only be accepted if the client has been informed and has provided consent.

Funding and Session Preferences

How do you plan to pay for your sessions?*

Self-managed

Plan-managed

Support Coordinator

GP Referral (medicare rebates plus gap fee)

Private Billing

Please include Name, Organisation, Contact Details (Phone and Email)*

Please select which areas you would be able to attend your appointment. Please select all that apply:*

Wollongong

Corrimal

Bellambi

Berkeley

Forbes

Condobolin

Telehealth

We offer sessions in-clinic and outside of clinic and via telehealth, depending on your needs. Please tell us if you have a preferred option:*

Indoors

Outdoors

Telehealth

I don’t have a preference

Does the client have capacity to sign their own Service Agreement?*

Yes

No

Name*

Relationship to Client*

Phone*

Email*

If the client is signing the agreement, who else requires a copy? (eg Parents, Support Workers, Support Coordinator, plan manager, etc)*

Who should be contacted to book and change appointments?*

Client

Other

Name*

Relationship to Client*

Phone*

Email

Who needs to receive appointment reminders?*

Client

Other

Name*

Relationship to Client*

Phone*

Email

Referral Information

Reason for seeking psychological therapy*

GOALS: What specific outcomes do you/ the client want to achieve by attending therapy?*

Diagnosis: (current and previous, physical and mental)*

Please provide information about how this impacts your/ the client’s wellbeing and functioning.

Have you/ the client seen a Psychologist or Counsellor before?*

Yes

No

If yes, please provide details (eg when did you see them? For how long? what was helpful or not helpful?)*

Have you/ the client seen a Psychiatrist before?*

Yes

No

If yes, please provide details (eg when did you see them? For how long? what was helpful or not helpful?)*

Do you/ the client take medication?*

Yes

No

If yes, please provide details*

COMMUNICATION AND LITERACY: Please describe any challenges that you/ the client experiences with reading or writing or communicating*

SAFETY: Please describe any safety concerns or behaviours that affect the client or others*

REGULATION: Describe any difficulties the client has with expressing emotions appropriately*

Is there a behaviour management plan in place?*

Yes

No

If yes, please provide brief details, and provide a copy on referral acceptance*

Is there anything else you would like us to know?

Support Network

Please provide details of your support network and healthcare team: (eg support coordinator, OT, physio, psychiatrist, GP, significant supports, etc)

(1) Support Name

(1) Support Role

(1) How often do you see them?

(1) Support Contact Details

(2) Support Name

(2) Support Role

(2) How often do you see them?

(2) Support Contact Details

(3) Support Name

(3) Support Role

(3) How often do you see them?

(3) Support Contact Details

(4) Support Name

(4) Support Role

(4) How often do you see them?

(4) Support Contact Details

Agreement & Consent

CLIENT TO COMPLETE: I give permission for Step Ahead Psychology to share and obtain information necessary for the provision of psychological care with those listed above:*

Yes

No

ON BEHALF OF THE CLIENT: I have discussed informed consent with the person named as the client on this form, and they have given verbal permission for Step Ahead Psychology to share and obtain information necessary for the provision of psychological care with those listed above:*

Yes

No

OR: As the client’s parent/ legal guardian, on behalf of the client I give permission for Step Ahead Psychology to share and obtain information necessary for the provision of psychological care with those listed above:*

Yes

No

Name*

First Last

Date*

DD slash MM slash YYYY

Signature*

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About Us

Step Ahead Psychology provides evidence-based counselling and psychological services for adults, children and adolescents located on the NSW South Coast and in the Central West.

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Assessments
Workshops
Animal Assisted Therapy
Employee Assistance Programs
Book Online

Contact Us

Head Office
Regus Office, Level 1
1 Burelli Street
Wollongong NSW 2500
02 4288 2591
info@stepaheadpsychology.com

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