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Referral Form

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Referral Form

Referral Form

Anyone can make a referral for services at Amelia Slater Community Wellbeing.

Please help us understand which support may suit you or the person you are referring best. The form below is not exhaustive, and we will do a thorough intake and biopsychosocial assessment when support begins with us.

If you would prefer a paper copy of this referral form, please contact us on admin@ameliaslater.com

Person's Information

First Name *

Last Name *

Email Address *

Phone Number *

NDIS Participant Number *

NDIS Plan Manager Name *

NDIS Plan Manager Email *

Referrer Information

Referrer Name *

Referrer Last Name *

ReferrerEmail Address *

Referrer Phone Number *

Referrer's Organisation

Referrer's Relation to Person

Services Required

What services can we provide you? (tick all that apply) *

Mental Health Social Work Therapy Counselling & Coaching Eye Movement Desensitisation and Reprogramming (EMDR) Therapy Trauma Counselling

Telehealth & Remote Services NDIS Social Work Therapy NDIS Support Coordination Psychosocial Recovery Autism Coaching & Support

Functional Capacity Assessment Workplace Psychological Safety & Wellbeing School-based Therapy Child, Family & Youth Services Other Social Work Services

ADHD Coaching & Support

Please provide more information about other services

Please provide more information about other services *

Has the person provided consent for this referral? Yes No

Person's Preferred Contact Method Phone Email Text Message

Additional Comments

By submitting this referral, you consent to this information being shared with the relevant health professional. You may revoke this consent at any time. Confidentiality and Privacy Notice: At Amelia Slater Community Wellbeing, we are committed to protecting the privacy of our clients and referrers. The information collected in this referral form will be used solely to facilitate the referral process and provide the necessary services to the client. We adhere to the Privacy and Data Protection Act 2014 (Vic) and the Health Records Act 2001 (Vic), which require us to manage personal information responsibly and ensure it is kept secure. Client Consent: By completing this referral form, you confirm that you have obtained the consent from the client to disclose their personal information for this referral. Storage and Access: All personal information collected will be stored securely and only accessible to authorized personnel. Disclosure: We will not share or disclose personal information to third parties without prior consent unless required by law. For further information about how we manage personal information, please email us at admin@ameliaslater.com

Acknowledgment of Country

Community Wellbeing acknowledges Aboriginal and Torres Strait Islander people as the Traditional Custodians of the land upon which we practice and recognises that sovereignty has not yet been ceded. We pay respect to Elders, past, present and emerging and support a Treaty.

Aboriginal and torres strait islander flags1

Diversity & Equity

Community Wellbeing is a safe, inclusive service provider that upholds social justice values towards equity and honours community diversity.

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Contact Details

Feel free to contact us. We look forward to hearing from you!

PO Box 70, Numurkah VIC 3636
amelia@ameliaslater.com
0422 035 204

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