Achieve Psychological Services

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A S

Professional

Psychological Services

Phone:

8678 0946

Offices at:

Marayong, St Marys Parramatta, Wetherill Park

Email:

[email protected]

ABN:

84 549 651 536

Achieve a Better Quality of Life Project Referral Form

Client Information First Name Last Name DOB Address Line 1 Gender Address Line 2 Postcode Contact Number Contact Number Email Referrer Details (if applicable) Name Relationship to client Service Email “Achieving A Better Quality of Life”

Services/Health Professionals Client Supported by (if different to referrer) Name Relationship to client Service Email Contact Number Name Relationship to client Contact Number Service Email Mental Health History Diagnosis Date of diagnosis Brief summary of mental health history/current presentation “Achieving A Better Quality of Life”

Physical Health History Do you/client experience or have a history of any of the physical health concerns listed: Diabetes Epilepsy Asthma Blood pressure issues Dental/hearing/eyesight issues Mobility issues Weight concerns Traumatic brain injury Cognitive deficits Past physical trauma Blood disorder Other Allergies Please provide any necessary details of above concerns: “Achieving A Better Quality of Life”

Overview Do you/client have a history or currently experience any of the concerns listed below. Please answer these questions as accurately as possible. Suicidal ideation Suicide attempts Self harm ideation Self harm Physical/verbal aggression Psychosis/mania Substance use Please provide any necessary details of above concerns: “Achieving A Better Quality of Life”

Consent I _________________________ give my consent for the health professionals and referrer nominated in this form to be contacted during the referral process. __________________________ ______________________________ _____________ Client’s Name Signature of Client or Legal Guardian Date __________________________ ______________________________ _____________ Witness Name Signature of Client Date Please attach paper to back of form if more space needed for any questions “Achieving A Better Quality of Life”

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