Referral: Psychologists Logan City & Redland City Referral Form

Date of Referral *

Date of Mental Health Care Plan

Preferred Practice Location *

SpringwoodThornlandsAgnes WaterBracken Ridge

Reason for Referral *

Type of Referral

GP Mental Health Care PlanBetter Outcomes / ATAPS (Type: General)Better Outcomes / ATAPS (Type: Peri-Natal Depression)Better Outcomes / ATAPS (Type: Suicide Prevention)Better Outcomes / ATAPS (Type: Child)WorkcoverDepartment of Veteran AffairsPrivate Insurance (e.g. Alliance, Suncorp etc)Employee Assistance ProgramAutism InitiativeBetter Start for Children with Diasabilites InitiativePrivateDon't Know / Unsure

Private Health Insurance

YesNo

Exisiting or New Client

New ClientExisting Client

How did you hear about us?

Meet and Greet with the Psych ProfessionalsPractice NurseOther GPWebsiteMarketing FlyerSchoolYellow PagesSocial Media ( Facebook etc)Walk By LocationOther

Referral

Please complete the details below and one of our team members will be in contact to organise your visit with us. Talk with you soon.

Doctor Details

Patient Details

Referral Details

Verification

Springwood Practice

Thornlands Practice

Bracken Ridge Practice