We are currently not taking any new clients until June 2025 We are currently not taking any new clients until June 2025 We are currently not taking any new clients until June 2025 Referral Form. We are currently not taking any new clients until June 2025 Who is filling out this form? * CLIENT/PARTICIPANT PARENT/NOMINEE SUPPORT COORDINATOR GP OTHER ALLIED HEALTH PROFESSIONAL Name of the person filling out this form * First Name Last Name Client/Participant's name * First Name Last Name Client/Participant's date of birth (we only see adults over the age of 18 years) * Does the client/participant identify as Aboriginal or Torres Strait Islander? * NO Aboriginal and Torres Strait Islander Aboriginal Torres Strait Islander Does the client/participant require an AUSLAN interpreter? * YES NO Does the client/participant require a language interpreter? * YES NO For non-NDIS clients: Please tell us your concerns in brief. For NDIS participants: Please indicate the access diagnosis. Preferred email to coordinate further communication regarding this referral. * Preferred phone number to contact regarding this referral. * (###) ### #### We are primarily a home-visit and telehealth-based service, but can offer in-office appointments where needed. Please indicate your preference. * Home-visit Videolink In-office (Underwood, QLD 4119) Please indicate your suburb or postcode * Preferred day or times for appointments. Participant's NDIS number if already funded by the NDIS. NDIS funding type * PLAN-MANAGED SELF-MANAGED AGENCY-MANAGED I AM NOT WITH THE NDIS Plan start date (NDIS participants only) Please enter in month/day/year format MM DD YYYY Plan end date (NDIS participants only) Please enter in month/day/year format MM DD YYYY Type of assessment needed (tick all that apply) * DIAGNOSIS FUNCTIONAL CAPACITY ASSESSMENT COGNITIVE/INTELLECTUAL ASSESSMENT HOME & LIVING NEEDS ASSESSMENT ASSESSMENT TO APPLY FOR NDIS ASSESSMENT TO APPLY FOR DSP ASSESSMENT FOR OTHER FORMAL SUPPORTS Any other helpful information regarding the referral, e.g. background, past diagnosis, assessments done, specific needs? If none, say "NO". * Current risks and alerts such e.g. aggression, seizures, current family violence situation, forensic orders, etc. If none, say "NO". * Any previously known difficulties engaging with allied health professionals? * YES NO NOT SURE I agree to Your Disability Psychology contacting me over the phone to discuss my assessment needs and providing me a quote for the service after the screening call. * Yes, thank you Thank you! Psychologist Tulsi Achia will contact you in 24-48 hours to clarify your assessment needs and guide you through the next steps.BE SURE TO CHECK YOUR SPAM FOLDER FOR REPLIES FROM US.