Referral Form

Change Futures secure online referral form for psychological services.

Please note that this form is specifically for third-party referrals only. If you are seeking assistance for yourself, kindly use the enquiry form instead.

Upon submission, your referral will be promptly processed. Our goal is to confirm service availability and book new clients within four weeks. If there are identified risks, we will prioritise contacting the client within 48 hours to address them. Thank you for choosing Change Futures. Your collaboration in providing the best possible care is greatly appreciated.

Services

For the dropdown selection, if you're unsure which service to choose, please select the option you believe best fits the referral.

Select a service (Required):

Important: please select "no" if this is not a risk referral

Risk Referral (Required): Region (Required):

Referrer Details

The fields below are relevant to the referrer

Referrer name (Required): Referrer profession: Referrer contact number (Must be 10 digits with no spaces. Example: 0738570874) (Required): Referrer email (Required): Referrer organisation (for aged care referrals, please select "other"): Referrer organisation / clinic name (Required): Referrer suburb and or city (Required): Referrer state: Referrer postcode:

Client Details

The fields below are relevant to the client

Preferred mode of delivery: Client family name (Required): Client given name (Required): Client preferred name: Client pronouns: Client gender: Client date of birth (Required): Client phone (Must be 10 digits with no spaces. Example: 0738570874) (Required): Client email: Client address (for aged care referrals, include name of aged care home and room number) (Required): Client suburb and or city (Required): Client state: Client postcode: Does the client consent to Change Futures leaving a voice mail or SMS? (Required) Does the client consent to this referral? (Required) Client country of birth: Client preferred language: Is the client of Aboriginal or Torres Strait Islander origin?

GP Details

The fields below are relevant to the client's GP

Please provide details if possible. GP name and GP practice suburb are required fields.

GP name (If GP name is not known type "Unknown".) (Required): GP Medicare provider number: GP practice: GP practice phone (Must be 10 digits with no spaces. Example: 0738570874) (Required): GP practice address: GP practice suburb and or city (If unknown type "Unknown") (Required): GP practice state: GP practice postcode: GP personal contact number (if applicable):

Referral Information

The following section will provide our professional staff with valuable insight prior to the initial engagement with the client.

What is the main reason for this referral? Please provide any information you think would be useful. (Required. Max 3000 characters.) Is the person at risk of harming themselves or others? Please detail aggressive behavior, suicidality/self-harm, plan, access to means, history of attempts, non-suicidal self-injury, and other relevant information. (Required. Max 3000 characters.) Are other agencies or treating professionals involved in this persons care? If so, please list. (Required. Max 3000 characters.) If there is other relevant information, please leave this information below. (Max 3000 characters.)

Submission Instructions

Please finalise your submission by clicking the "Submit" button below. After submission, a new form will be available for any subsequent referrals. Thank you.

Please enter the correct letters.