PeachTree Mental Health Referral Form

Below are some questions to help us understand you better and provide the support you need. Some are optional; just share what feels right for you. The more you tell us, the better we can assist.

First Name: Last Name:

Preferred Name: Gender:

Date of Birth: Current Age:

Street Address:

Suburb: State: Post Code:

Phone Number: Email Address:

Parent / Caregiver Information (if applicable)

Caregiver Name: Relationship to Child:

Phone Number: Email Address:

Referrer Information (if applicable)

Referrer Name: Referring Organisation:

Referrer Phone Number: Referrer Email Address:

Has the person you're referring given their consent for this referral?

Yes No

What type of support are you looking for?

Counselling
NDIS Psychosocial Supports
Supervision
Assessment

Tell us a bit about why you're seeking support:

You're welcome to share anything that helps us understand your needs.

Funding Details (if applicable)

Please fill in any details that apply to you. If you're not sure, just leave blank.

Do you have a Mental Health Treatment Plan from your GP? Yes No

Medicare Card Number:

Reference Number:

Expiry Date (MM/YY):

Referring GP / Practice:

NDIS Number:

NDIS Plan Start Date (if known):

NDIS Plan End Date:

Self-managed Plan Managed Agency-managed

If Plan Managed, please provide your Plan Manager Details:

Private Health Cover Details:

How did you hear about us?

If you have any accessibility needs, or there is anything else you would like to share, please provide details:

Please note:
PeachTree Mental Health is not a crisis service. If you or someone else is at immediate risk, please contact Lifeline on 13 11 14, call 000, or visit your nearest emergency department.