Make a referral.

Complete the form below and we'll respond within one business day. Complex, forensic and high-risk participants welcome — including those who've experienced previous service breakdowns. Urgent and crisis presentations are prioritised. You can submit online, or print this pack to complete by hand.

Emailreferrals@therapymentalhealth.com.au

Phone0428 368 465

ResponseWithin 1 business day

Referrer details

Your name Role / title Organisation Referrer type Email Phone

Participant details

Participant name Date of birth Pronouns (optional) Phone (if contactable) Suburb State Cultural background (optional) Interpreter required? Living situation

NDIS plan details

NDIS number Primary disability / diagnosis (NDIS) Plan management Plan start date Plan review date

Plan manager details — if plan-managed

Plan manager / organisation Plan manager email Plan nominee / decision-maker Plan manager phone

Supports requested

Select all that apply.

Clinical & risk summary

Primary diagnoses / presentation Reason for referral & goals Known risks & safety considerations

Current treating team / case manager Referral urgency

Attachments

Attach the NDIS plan and any supporting documents. The more context we have, the faster we can respond. Accepted: PDF, Word, JPG, PNG.

If files are too large to attach here, email them to referrals@therapymentalhealth.com.au with the participant's name.

Consent

The participant (or their authorised decision-maker) consents to this referral and to Therapy Mental Health being contacted about it. Consent has been given to share relevant clinical and risk information for the purpose of assessment and support planning. I understand information is handled in line with Therapy Mental Health's privacy obligations and the NDIS Code of Conduct.

Signature (name) Date

Submit by email Prefer to talk it through first? Call our intake team on 0428 368 465.