Referral Form

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Make a mental health referral

Anyone can make a mental health referral here, including referring yourself. You don't need a GP or anyone else to refer you first.

Referring as a GP, support coordinator, or allied health professional

Submit the form below to refer a client. I am an Accredited Mental Health Social Worker, offering social work services, EMDR and trauma therapy for neurodivergent women, gender-diverse people and other people working through difficult circumstances and experiences. I work with private clients, self-managed or plan-managed NDIS participants, and offer rebates in some circumstances.

This shouldn't take more than a couple of minutes. I'll get back to you within 5 business days.

Sections appear based on your answers, so you only see what's relevant.

If filling this in feels like too much, you can email me directly: amelia@ameliaslater.com.

Who is making this referral?

Are you referring yourself or someone else?*

How is this being funded?

I work with people on Self-managed and Plan-managed NDIS plans, and several other funded support schemes. I'm not a registered NDIS provider, so I can't currently support people on NDIA-managed plans.

How are you looking to fund these sessions?*
Are you an NDIS participant?*
Optional. If you've got it handy, sharing it now saves a step later.
How is your plan managed?*
Optional. Name of your plan manager and any contact details, if handy. Saves a step later.

I can't currently support NDIA-managed plans

I'm not a registered NDIS provider, so the NDIA can't pay for my services directly. If your plan is NDIA-managed, you have a few options:

  • Ask your planner or Local Area Coordinator about switching to Plan-managed at your next plan review
  • Use private funding for now, if that works for you
  • Email me so we can talk it through: amelia@ameliaslater.com

Would you like to keep going with this referral anyway? I can still get back to you and we can work out next steps.

Would you like to keep going?*

Other funded support

A few questions to confirm fit.

Which type of funded support are you using?* Tick all that apply.
Optional. Claim numbers, referrer details, expiry dates, anything that'll save us a back-and-forth later.

Tell me a bit more

Just the essentials so I can email you with options.

A few sentences is plenty. What's bringing you here, and anything I should know.

Your details

Just the basics so I can get back to you.

Optional. Useful if you'd prefer a call or text.
Your pronouns Optional. Tick any that fit, or write your own.
Anything you'd like to share? Optional. Pick whichever feels easier.
What's bringing you here? Tick any that fit. None of these need to be a formal diagnosis. We can talk through everything when we connect.
Optional. As much or as little as you like. We can talk about everything when we connect.
Is the person you're referring an NDIS participant?*
Optional. If you've got it handy, sharing it now saves a step later.
How is their plan managed?*
Optional. Name of their plan manager and any contact details, if handy. Saves a step later.

I can't currently support NDIA-managed plans

I'm not a registered NDIS provider, so the NDIA can't pay for my services directly. If their plan is NDIA-managed, there are a few options:

  • Ask their planner or Local Area Coordinator about switching to Plan-managed at the next plan review
  • Use private funding for now, if that works
  • Email me so we can talk it through: amelia@ameliaslater.com

Would you like to keep going with this referral anyway?

Would you like to keep going?*

Other funded support

A few questions to confirm fit.

Which type of funded support are they using?* Tick all that apply.
Optional. Claim numbers, referrer details, expiry dates, anything that'll save you a back-and-forth later.

Tell me a bit more

Just the essentials so I can email you with options.

A few sentences. Who you're referring, what's bringing them here, and anything I should know.

About you

Optional.
A few words is fine. e.g., parent, partner, friend, GP, support coordinator, social worker, teacher.
Your pronouns Optional. Tick any that fit, or write your own.

About the person being referred

Their pronouns Optional. If you know them. Tick any that fit, or write them in.
How would you like me to make contact?*
Optional.

Consent and anything else

Does the person being referred know about this referral?*
Anything you'd like to share? Optional. Pick whichever feels easier.
What's bringing them here? Tick any that fit. None of these need to be a formal diagnosis. We can talk through everything when we connect.
Optional. As much or as little as you like.

Anything urgent? Call directly: 0422 035 204

Get in touch

If you're thinking about counselling, want to check whether I'm a good fit, or have questions about how I work, here's how to reach me. I read everything and reply within a few business days.

Acknowledgement of Country

I acknowledge the Yorta Yorta people as Traditional Custodians of the land upon which I practise, and the Traditional Custodians of all other lands across this continent where my clients live and work. I recognise that sovereignty was never ceded. I pay respect to Elders, past and present, and support a Treaty.

I provide a safe, inclusive service that upholds social justice values towards equity and honours community diversity.

Read our Privacy Policy and Risk Management Policy.
Self-refer or refer a client via the Referral form.
Existing clients can sign in to the Client Portal.

PO Box 70
Numurkah VIC 3636

Accreditation

AASW Accredited Mental Health Social Worker Youth Workers Australia Member Natural Therapist Certified Member EMDR Level 2
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