Melbourne Art Therapy form

MELBOURNE ART THERAPY STUDIO
Abbotsford Convent Arts Precinct
Convent Building
Studio C2.26 1 St Heliers Street
Abbotsford Vic 3067
Ph: (03) 8415 0052

info@melbournearttherapy.com.au

Referral Form

Date Referral Completed:
Day:
 month

 year

PROSPECTIVE CLIENT DETAILS

Name:
Address

postcode
Date of Birth
Day:
 Month:
 Year:

Phone (home):

Phone (mobile)
Email

**if under 18, please complete details below**

Parent / Guardian name :
Address

postcode

Phone (home):

Phone (mobile)
Email

 

REFERRER DETAILS (for agencies / health professionals)

Name of referrer (your name):
Name of Agency you are affiliated with:
What is your relationship to the client?
Your Contact Details:

 
Phone
Email

 

REASONS FOR REFERRAL

Briefly describe the main issues / concerns that led to this referral
How long have these issues / concerns been a problem?
Is the client aware that you are making this referral?


Please note, clients will only be contacted if they are aware of, and in agreement with the referral being made

CLIENT BACKGROUND INFORMATION

To assist with establishing client needs / tailoring our service, please circle the relevant words.

Client’s Current Mood:
Frustrated
Agitated
Sad
Depressed
Tearful
Angry
Aggressive 		Stressed
Tense
Worried
Lonely
Isolated
Irritable
Moody
Current Supports From Family / Friends:

Few supports available

Moderate support

Strong supports
Client’s Hope For Change:


Current Medications:

Antidepressants
Sleeping Pills

Anti-anxiety meds
Current medical illness: Yes No Don’t know
Current problematic alcohol / drug use: Yes No Don’t know
Current or past thoughts of suicide: Yes No Don’t know
Suicide attempt/s: Yes No Don’t know
History of aggression / violence towards others: Yes No Don’t know
Current or past problems with domestic violence: Yes No Don’t know
Current or past trouble with the law: Yes No Don’t know
If Yes to any of the above, please elaborate:
   

HEALTH PROFESSIONALS INVOLVED

Please indicate which professionals are currently involved in this person’s emotional or physical health care (Note : we will not contact any people listed without obtaining the client’s permission first).

Please provide name, location and phone number of the relevant health professionals.

General Practitioner:
Medical Specialist:
Counsellor / Psychologist:

Psychiatrist:
Case Manager / Social Worker:
Physiotherapist:

Occupational Therapist:
Other

 

 

 

URGENCY OF REFERRAL

Please rate how urgent this referral is, and give reasons:
Very Urgent
Moderately Urgent
Can Wait
Any other information:


Information for New Clients / Cancellation Policy

I have read and accept the information for new clients & cancellation policy: Yes