MAKE A REFERRAL

Please note:

Once your referral is submitted, Renee from my admin team will be in contact to book a 15 minute enquiry call to ensure I am the right therapeutic fit for you. Please refer to our Frequently Asked Questions on our About page to clarify my clinical focus and the clients I have developed further skills in supporting.

Following the July 2025 NDIS guidelines, appointments that require travel time that exceed thirty minutes (one hour of total travel time) from Armadale, Melbourne will be via Telehealth or a gap fee will be incurred.

How did you hear about Our Mindful Youth?

Where would you like to have your sessions?

Referral Date

Services requested

Purpose of therapy

Who are you referring?

Name

Preferred pronouns

Birthday

Address

Who is this submitting this referral?

Name

Role in clients life

Phone

Details of NDIS Support Coordinator (if applicable)

Who is the best contact for this client

Name

Role in clients life

Phone

Address

Preferred day and time of contact

Medical details

GP name

Phone

GP address

Please outline clients medical history / diagnoses:

Please outline clients mental health history / diagnoses:

Does the client have a history of trauma? YES / NO (experienced an event that was so frightening, horrible or traumatic that it still now, distresses you.) If yes, please outline history:

Does the client have a history of physical or verbal aggression towards others? YES / NO If yes, please outline history:

NDIS details
(Please write NA if not relevant)

Please note: we can only invoice self and plan managed NDIS clients.)

NDIS number:

NDIS plan management: Self managed / Plan managed

NDIS plan dates:

Invoicing details

Name of those responsible for paying invoices (if self or plan managed):

Agency name:

NDIS funded hours dollar

Referral reason and goals

Emotional trigger identification

Services location request

MAKE A REFERRAL

Who are you referring?

Who is this submitting this referral?

Who is the best contact for this client

Medical details

NDIS details
(Please write NA if not relevant)

Please note: we can only invoice self and plan managed NDIS clients.)

Invoicing details

@ourmindfulyouth

Please note that all communication with Our Mindful Youth is via our contact form or email, Tessa's phone number is accessible once referral is accepted.

MAKE A REFERRAL

Who are you referring?

Who is this submitting this referral?

Who is the best contact for this client

Medical details

NDIS details (Please write NA if not relevant) Please note: we can only invoice self and plan managed NDIS clients.)

Invoicing details

NDIS details
(Please write NA if not relevant)

Please note: we can only invoice self and plan managed NDIS clients.)