Make a referral

How did you hear about Our Mindful Youth?

Which location are you referring to?

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

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 (if relevant)
(please note, we can only invoice self and plan managed NDIS clients.)

NDIS details

NDIS number:

NDIS plan management: Self managed / Plan managed / NDIA managed

NDIS plan dates:

Invoicing details

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

Agency name:

NDIS funded hours and / dollar amount from Improved Daily Living being allocated to Our Mindful Youth services (exact amount):

Why are you referring this client?

Referral reason and goals

Emotional trigger identification

Where do you require services?

Services location request

NDIS PLAN UPLOAD

Upload File

Upload supported file (Max 15MB - please compress if file exceeds this size or email through to details below).

* If you cannot upload your NDIS plan above, please email a copy of your plan to admin@ourmindfulyouth.com.au to reflect your NDIS goals, and show how the sessions will be funded.

** There may be circumstances where a client's support needs may exceed the capacity of Our Mindful Youth's services, and the skills of those employed by Our Mindful Youth. In these circumstances Our Mindful Youth will contact you as soon as possible to discuss your support options. Those accessing Our Mindful Youth services through their NDIS supports have the choice of the service provider delivering their skill building supports. In some circumstances (such as not meeting client needs) Our Mindful Youth may not be the most ideal service provider. If the range/type of services provided by Our Mindful Youth do not best meet the needs of a participant, Our Mindful Youth encourages clients to source more suitable services.

Due to July 2025 NDIS guidelines, appointments that require travel time that exceeds 30 mins from Armadale will be via Telehealth or a gap fee will be incurred. Please advise your preference in the referral form below

About referrals:

All referrals are managed by our admin staff. They will gain an understanding of any difficulties and goals for therapy, and make an initial appointment with the most appropriate clinician, also providing you with our Welcome Paperwork and Service Agreements. If clinicians are at full capacity at the time of your referral, you will be placed on a waiting list. You will be contacted as soon as possible following the submission of your referral.

** Please note, should you have any difficulty filling out the online form, please ensure you have answered all questions with an asterisk beside them. This form can not be submitted without these filled in.

Alternatively, you can print and fill in our referral form manually, and email it through to admin@ourmindfulyouth.com.au. This is found above as a PDF file.

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 (if relevant) (please note, we can only invoice self and plan managed NDIS clients.)

NDIS details

Invoicing details

Why are you referring this client?

Emotional trigger identification

Where do you require services?

NDIS PLAN UPLOAD

Due to July 2025 NDIS guidelines, appointments that require travel time that exceeds 30 mins from Armadale will be via Telehealth or a gap fee will be incurred. Please advise your preference in the referral form below

About referrals:

​

** Please note, should you have any difficulty filling out the online form, please ensure you have answered all questions with an asterisk beside them. This form can not be submitted without these filled in.

​

Alternatively, you can print and fill in our referral form manually, and email it through to admin@ourmindfulyouth.com.au. This is found above as a PDF file.

​

​

NDIS details (if relevant)
(please note, we can only invoice self and plan managed NDIS clients.)