OUTPATIENT REFERRAL FORM PSYCHOLOGICAL ASSESSMENT AND TREATMENT
Axis Psychology Clinic is a private psychology clinic with a number of psychologists who
have experience working across various mental health and psychiatric settings. Axis
Psychology Clinic works closely with psychiatrists and programs at New Farm Clinic.
To send a referral, phone Axis Psychology Clinic on (07) 3252 7898, Fax on (07) 3852
4629, or post to Suite 2A / 76 Commercial Road Newstead QLD 4006. Internally at New
Farm Clinic referrals can be left in the Psychology folder in the Consulting Suites for pick
up.
Date: ________________________________________
I wish to refer the following patient for Psychological Assessment and Treatment.
Name: ________________________________________ D.O.B: _____________________________________________
Day Phone: ___________________________________ Mobile: ___________________________________________
Referrer: _____________________________________ Contact Number: ________________________________
Diagnosis: __________________________________________________________________________________________
______________________________________________________________________________________________________
Assessment / Treatment Goals: __________________________________________________________________
______________________________________________________________________________________________________
Referral Options:
 Specific Psychologist Requested: ________________________________________________________
Or specific area of expertise required:
 Clinical Neuropsychologist
 Eating Disorder
 DBT therapist
 Complex trauma
 Child or Adolescent psychologist
 Psychosis
 CBT
 Chronic Pain
Signature: __________________________________________________________________________________________
If you think your patient would benefit from inclusion in one or any combination of
Group Therapy Programs offered at New Farm Clinic, please complete the attached form
and return to New Farm Clinic (for doctors with admitting rights to New Farm Clinic).